Care Disparities Persist Among White, Minority Patients With Rheumatoid Arthritis

Efforts to close the gap in quality of care for rheumatoid arthritis (RA) between America’s White population and its racial and ethnic minorities are failing, and it is critical to reevaluate how to combat this intractable problem, 2 New York-based specialists wrote in Current Opinion in Rheumatology.

Kevin Yip, MD, and Iris Navarro-Millán, MD, cited evidence of inequitable care for RA across the board, ranging from a predominant focus on White populations in research to inequities in prescribing patterns and access to health care.

“Given the differences and burden of disease on non-White populations delineated in this article, it is imperative that we better understand why discrepancies exist on every level, system, physician, patient, and illness level, if we are to fix the problem,” they wrote. “This will require us to revisit the policies that contributed to bring us and our health care system to this unequal state to begin with, so we can right this wrong.”

A study the authors pointed to found that patients living in an area with low socioeconomic status and who were low income, male, and African American were less likely to be prescribed biological disease-modifying antirheumatic drugs (bDMARDs). African Americans (49.3%) were less likely to receive bDMARDs than Whites (53.3%) and Hispanics (60.9%). Another study found that patients in a veterans registry had greater odds (odds ratio, 1.66) of receiving biologics compared with non-White counterparts from an ethnic minority RA database.

Data also show that disability in RA leads to high opioid use for all racial/ethnic groups, with more than 66% of Social Security disability recipients receiving the drugs on a regular basis, they wrote. With African Americans receiving inferior treatment, the result is greater likelihood of overreliance on opioids.

“As early treatment is beneficial for earlier remission, prevention of joint damage, and disease-related disability, it stands to reason that minorities without equitable access to care will accrue and be exposed to longer uncontrolled disease before therapy and therefore have poorer progress and remission rates,” they wrote.

Since 2010, HHS has made health disparities a priority through its Healthy People initiative. Even so, most epidemiological studies, outcomes, and trials of patients with RA include primarily White patients or provide no information on race, Yip and Navarro-Millán wrote.

Statistics they cited show racial minorities represent 41% of the US population, but only 16% of those in randomized controlled trials. Efforts to increase awareness and participation from both researchers and patients had little effect on improvement of minority representation over the 10-year period ending in 2018.

A systematic review of 240 RA randomized controlled trials from 2013 found an overrepresentation of the White population, ranging from 74.6% to 97.0%, the authors noted. Lack of racial/ethnic data hinders the medical community’s ability to understand the contours of the disparities. Such research disparities are not always the case, with more equitable representation, for example, in lupus and diabetes.

A longitudinal study also found a link between RA and financial status, they wrote. Patients at financial risk were disproportionately affected by severe RA and twice as likely to be a minority. Out-of-pocket costs have been shown to be a barrier to patients adhering to their medication regimen.

Another study found non-White patients were more likely to be in a public than private clinic (83% vs 18%) and to wait significantly longer before receiving DMARD therapy (median of 7 years vs 1 year).

“These findings suggest intrinsic biases, which prevent the same level of access and care to racial minorities, are a crucial barrier in rheumatoid arthritis where early treatment can prevent long-term damage,” Yip and Navarro-Millán wrote.

There are few data to indicate that individuals in specific minorities have more aggressive or higher disease activity, they wrote. A study of 6008 patients found similar clinical disease activity index scores.

Health disparity is not confined to only race, they wrote. Disparities by sex, sexual identity, disability, and age also persist, they wrote.

“Further research is needed to tease the complex interplay between race, social economic status, medical access, and outcomes to explain the disparities found in rheumatoid arthritis,” they concluded.

Reference

Yip K, Navarro-Millán I. Racial, ethnic, and healthcare disparities in rheumatoid arthritis. Curr Opin Rheumatol. 2021;33(2):117-121. doi:10.1097/BOR.0000000000000782