Rheumatoid Arthritis Patients Not Getting Recommended Drugs

Despite medical guidelines recommending that patients receive early and aggressive treatment for rheumatoid arthritis with these medications, only 63 percent of Medicare-managed care patients diagnosed with the disease received any amount of the prescription drugs, according to a new study led by a researcher from the Stanford University School of Medicine that will be published Feb. 2 in the Journal of the American Medical Association.

"Among patients with a true diagnosis of rheumatoid arthritis, closer to 90 percent should be receiving treatment," said Gabriela Schmajuk, MD, a postdoctoral scholar in the Division of Immunology and Rheumatology and lead author of the study. The study's senior author is Jinoos Yazdany, MD, MPH, adjunct assistant professor of rheumatology at the University of California-San Francisco.

Which patients receive these medications also varies dramatically by their health-care plan, their economic status and where they live, the study found.

The medications, called disease-modifying antirheumatic drugs or DMARDs, have long been available, but in the past 12 or 13 years many more new versions of the drugs have entered the market. Costs range from many thousands of dollars per year for some of the newer medications to a few hundred dollars for a year of treatment with some of the older drugs.

"We counted patients who received the bare minimum amount of treatment, and still a large proportion of patients aren't getting the medication they need," said Schmajuk. "We set the bar very low."

Rheumatoid arthritis is a chronic, painful disease that leads to inflammation of the joints and surrounding tissues. The cause is unknown, but it's considered an autoimmune disease. The body's immune system, instead of attacking foreign substances such as viruses, turns on itself. About 1.3 million Americans have rheumatoid arthritis and three-fourths of them are women. There is no known cure, and it usually strikes between the ages of 30 and 60.

"The reason treatment is so important is that if left untreated one-third of patients with rheumatoid arthritis will become disabled within five years of diagnosis," Schmajuk said. "The disease primarily affects the hands. Frequently patients are unable to work because they can't use their hands."

The study examined variations in medication treatment of 93,143 patients with rheumatoid arthritis who were at least 65 years old between 2005 and 2008. The researchers got the information from the Centers for Medicare and Medicaid HEDIS database.

HEDIS is a widely used set of performance measurements in the managed-care industry developed and maintained by the National Committee for Quality Assurance. It was designed to allow consumers to compare a health plan's performance with other plans and to national and regional benchmarks. In 2005, the database added reporting of the receipt of DMARDS among patients with rheumatoid arthritis.

Commercial health plans participate voluntarily in reporting to the database, but Medicare-managed care plans are required to report results.

"We found that certain groups were not receiving the medication they needed," Schmajuk said. "Patients who had low income received DMARDs less frequently than wealthier patients. Blacks received medications less frequently than whites. We also found that patients who lived in the mid- and south-Atlantic regions received medications less frequently than other areas, particularly the West Coast states."

Researchers also found that treatment varied dramatically between health-care plans.

"Some plans were doing really well with over 80 percent of patients being treated appropriately," Schmajuk said. "Others plans had fewer than 20 percent of patients getting appropriate care, which is really worrisome. We know this wasn't because of the individual characteristics of patients since the health plan results were adjusted for age, race, income and geographic region."

The database included about 300 different health-care plans nationwide. Researchers didn't investigate the causes of the variations in treatment and could only speculate.

"Some health plans might have different policies about when patients can see certain specialists," Schmajuk said. "Or one health-care plan might have one rheumatologist for 5,000 patients versus another that provides one for every 500 patients."

Consumers can search for the reported results from Medicare-managed care plans at www.ncqa.org.

Eliza Chakravarty, MD, assistant professor of immunology and rheumatology at Stanford, was a co-author of the study. Other authors who contributed to the study were from UCSF, Brown University and Harvard University.

Funding was provided by the American College of Rheumatology/Research and Education Foundation Physician-Scientist Development Award; National Center for Research Resources; Rosalind Russell Medical Research Center for Arthritis; National Institutes of Health; State of California Lupus Fund; Arthritis Foundation; Agency for Healthcare Research and Quality; and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

More information about Stanford's Department of Medicine, which supported the study, is available at medicine.stanford.edu/

The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit mednews.stanford.edu. The medical school is part of Stanford Medicine, which includes Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For information about all three, please visit stanfordmedicine.org/about/news.html