Initiation of disease-modifying antirheumatic drug therapy in minority and disadvantaged patients with rheumatoid arthritis

Objective. To evaluate disparities in time to initiation of disease modifying antirheumatic drugs (DMARD) in patients with rheumatoid arthritis (RA) receiving care in public or private healthcare settings. Methods. We reviewed the records of patients with RA initially seen at one of 2 rheumatology clinics: a clinic in a public county hospital providing care primarily to minority, disadvantaged, or uninsured patients, and a private clinic providing care to patients with health insurance coverage. Both clinics were affiliated with the same medical school. We determined time to initiation of DMARD or steroid therapy using Kaplan-Meier analyses and Cox regression. Time to initiation of therapy was measured from onset of disease until a therapy was prescribed (event) or the patient was seen for the first time at one of the 2 clinics (censored at index visit). Independent variables were ethnicity and clinic setting (public or private). Results. One hundred eighteen new patients with RA were seen in the public setting, 167 in the private setting; 83% of the patients in the public clinic and 18% in the private setting were non-White. Survival analysis (disease duration ≤ 10 yrs) showed that the median time to initiation of DMARD therapy was 6 years for the public clinic and 1.5 years for the private clinic (p = 0.001), and 7 years for non-White patients, compared to 1 year for White patients (p < 0.0001). For patients with disease duration ≤ 5 years, significant differences were observed for both clinic and ethnicity, with more patients in the private clinic (62%) than in the public clinic (32%) and more White (64%) than non-White (32%) patients having received treatment. Conclusion. These findings suggest that ethnic minorities and uninsured patients are at risk of deleterious outcomes as a consequence of delayed therapeutic onset.