Geographic Variation in Disease Burden and Mismatch in Care of Patients With Rheumatoid Arthritis in the United States

OBJECTIVE

Our objective was to evaluate the factors associated with regional variation of rheumatoid arthritis (RA) disease burden in the US.

METHODS

In a retrospective cohort analysis of Rheumatology Informatics System for Effectiveness (RISE) registry data, seropositivity, RA disease activity (Clinical Disease Activity Index [CDAI], Routine Assessment of Patient Index Data-version 3 [RAPID3]), socioeconomic status (SES), geographic region, health insurance type, and comorbidity burden were recorded. An Area Deprivation Index score of more than 80 defined low SES. Median travel distance to practice sites' zip codes was calculated. Linear regression was used to analyze associations between RA disease activity and comorbidity adjusting for age, sex, geographic region, race, and insurance type.

RESULTS

Enrollment data for 184,722 patients with RA from 182 RISE sites were analyzed. Disease activity was higher in African American patients, in those from Southern regions, and in those with Medicaid or Medicare coverage. Greater comorbidity was prevalent in patients in the South and those with Medicare or Medicaid coverage. There was moderate correlation between comorbidity and disease activity (Pearson coefficient: RAPID3 0.28, CDAI 0.15). High-deprivation areas were mainly in the South. Less than 10% of all participating practices cared for more than 50% of all Medicaid recipients. Patients living more than 200 miles away from specialist care were located mainly in Southern and Western regions.

CONCLUSION

A disproportionately large portion of socially deprived, high comorbidity, and Medicaid-covered patients with RA were cared for by a minority of rheumatology practices. Studies are needed in high-deprivation areas to establish more equitable distribution of specialty care for patients with RA.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

PURPOSE

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

METHODS

We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

RESULTS

There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

CONCLUSIONS

Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Association of atherogenic indices with C-reactive protein and risk factors to assess cardiovascular risk in rheumatoid arthritis patient at Tikur Anbessa Specialized Hospital, Addis Ababa

Background

Rheumatoid arthritis (RA) is an autoimmune systemic chronic inflammatory disorder, which is characterized by joint stiffness, damage, and destruction of bone. In RA patients, the risk of cardiovascular disease is increased by 2–3 folds as compared to the general population. The major burden of RA is the development of cardiovascular diseases, including congestive heart failure, stroke, and myocardial infarction.

Objectives

Assessment of the association of atherogenic indices with C-reactive protein to evaluate CVD risk was one of the purposes of this study. In addition, the association of atherogenic indices with elevated levels of cardiovascular risk factors (LDL-C and TG) was another aim of this study.

Methods

The preferred study design for this study was a hospital based comparative cross-sectional study method. Data were cleaned, coded, and entered into Epi Data version 4.6 software, and exported to SPSS version 20 for further analysis of atherogenic indices, C-reactive protein, and risk factors. The comparison of atherogenic indices and other variables among the case and control groups was estimated by the independent t-test statistical analysis method. All variables with a p-value less than 0.2 during binary linear regression analysis were selected for multinomial logistic regression analysis. The association of atherogenic indices with C-reactive protein and risk factors was computed using multiple logistic regressions. The data were presented using tables and figures for clarification of the study.

Results

The levels of atherogenic indices were computed for both RA patients and the control group. The values of atherogenic indices were significantly associated with cardiovascular risk factor (CRP ≥ 2mg/L). Atherogenic index of plasma (AIP) and TC/HDL-C ratio had a statistically significant association with an elevated levels of triglycerides (P<0.01). The TC/HDL-Cratio value of the patient had 2.38 folds more likely to have an elevated low density lipoprotein level. In addition, AIP of RA patients had 57.51 and 23.65 folds more to have elevated low density lipoprotein and triglycerides respectively.

Conclusions

The result of this study showed that TC/HDL-C, LDL/HDL-C ratio values, and atherogenic index of plasma had a statistically significant association with elevated level of low density lipoprotein and triglycerides. In addition to this, they have a statistically significant association with the level of C-reactive protein. There was a highly significant statistical association between atherogenic indices, elevated low density lipoprotein, and triglycerides values. Therefore, the result of this finding confirmed that atherogenic indices have a potential role in the prediction and management of CVD risk in RA patients.

A Population-Based Study Evaluating Retention in Rheumatology Care Among Patients With Rheumatoid Arthritis

Objective

The study objective was to assess adherence to system‐level performance measures measuring retention in rheumatology care and disease modifying anti‐rheumatic drug (DMARD) treatment in rheumatoid arthritis (RA).

Methods

We used a validated health administrative data case definition to identify individuals with RA in Ontario, Canada, between 2002 and 2014 who had at least 5 years of potential follow‐up prior to 2019. During the first 5 years following diagnosis, we assessed whether patients were seen by a rheumatologist yearly and the proportion dispensed a DMARD yearly (in those aged ≥66 for whom medication data were available). Multivariable logistic regression analyses were used to estimate the odds of remaining under rheumatologist care.

Results

The cohort included 50,883 patients with RA (26.1% aged 66 years and older). Over half (57.7%) saw a rheumatologist yearly in all 5 years of follow‐up. Sharp declines in the percentage of patients with an annual visit were observed in each subsequent year after diagnosis, although a linear trend to improved retention in rheumatology care was seen over the study period (P < 0.0001). For individuals aged 66 years or older (n = 13,293), 82.1% under rheumatologist care during all 5 years after diagnosis were dispensed a DMARD annually compared with 31.0% of those not retained under rheumatology care. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist decreased the odds of remaining under rheumatology care.

Conclusion

System‐level improvement initiatives should focus on maintaining ongoing access to rheumatology specialty care. Further investigation into causes of loss to rheumatology follow‐up is needed.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

The use and context of the term 'multimorbidity' in rheumatoid arthritis: a systematic literature review

This systematic literature review aimed to analyse terms describing coexisting conditions in the RA literature, informing the need for an operationalized definition of multimorbidity. Articles discussing RA with multimorbidity, published 1946 until August 2020, were identified. The primary outcome was the use and/or definition of 'multimorbidity' in RA. Information extracted included terms defining coexisting conditions, the use of a comorbidity/multimorbidity score and the use of 'index disease' to describe RA (more applicable to comorbidity than multimorbidity). Thirty-nine articles were included. Eight articles used the term 'multimorbidity', 18 used 'comorbidity' and 12 used both terms, 7 synonymously. One used no term. Fourteen articles fully defined the term. The number of co-existing conditions described in included studies was one-121. Twelve articles used a comorbidity/multimorbidity score. Four articles described RA as the 'index disease'. Our results demonstrate inconsistent use of the term multimorbidity. Improved assessment of multimorbidity is indicated in RA patients, including an operationalized use and definition.

The association between increased body mass index and response to conventional synthetic DMARD treatment in rheumatoid arthritis: Results from the METEOR database

BACKGROUND

Few data exist on the association between increased BMI and response to conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) in rheumatoid arthritis (RA).We aimed to explore the association between increased (overweight or obese) BMI on csDMARD-prescribing, methotrexate-dose and disease activity over 12-months.

METHODS

Participants in an international RA database were stratified into early (<1year post-diagnosis) and established RA. EULAR response, DAS28 remission and treatments were recorded at baseline, 6-months and 12-months. Increased BMI was explored in early and established RA, as predictors of good EULAR response, DAS28 remission, number of csDMARDs and methotrexate-dose, using logistic and linear regression.

RESULTS

Data from 1313 patients, 44.3% with early RA, were examined. In early RA, increased BMI was not significantly associated with remission. In established RA, obese patients on monotherapy were significantly less likely to achieve good EULAR response or DAS28 remission at 6 months and more likely to be treated with combination csDMARDs, compared with normal BMI. In patients taking methotrexate, overweight and obese patients with early and established RA were exposed to higher methotrexate doses (mono- and combination-therapy), with a mean dose of 20mg/week, compared to 15mg/week in those of normal BMI.

CONCLUSION

We observed, compared to patients with normal BMI, overweight and obese individuals experienced more intensive csDMARD exposures. Similar response rates were observed in early RA but increased BMI was associated with reduced response in established RA. Optimisation of targeted RA treatment remains important, particularly in those with increased BMI where response in established disease may be attenuated.

Socioeconomic status and occurrence of chronic pain: a meta-analysis

OBJECTIVE

To examine the association between socioeconomic status (SES) and the occurrence of chronic pain, defined as pain that persists or recurs for >3 months.

METHODS

We performed a structured search in Medline, Embase, WHO Global Index Medicus and Conference Proceedings Citation Index-Science databases to identify cohort and case-control studies on chronic pain and SES and its subgroups (SES combined index, educational level, income and occupational status). We extracted study characteristics, outcome measures and measures of association and their 95% CIs. Literature search, data extraction and risk of bias assessment were conducted by two independent researchers. We performed main and subgroup meta-analyses using random-effects model, and formally assessed heterogeneity and publication bias.

RESULTS

A total of 45 studies, covering a population of ∼175 000 individuals, were meta-analysed, yielding a pooled Odds Ratio (OR) of 1.32 (95% CI: 1.21, 1.44) and 1.16 (95% CI: 1.09, 1.23) for low and medium SES levels, respectively, compared with high level. We obtained similar results in all the subgroup analyses. Heterogeneity was generally moderate to high across strata, and some evidence of publication bias for low socioeconomic status was found.

CONCLUSION

Our results support a moderate increase in the risk of chronic pain for low and medium SES when compared with high SES, a feature that remained constant in all measures of exposure or outcome used. Further prospective research on populations from developing countries are needed to confirm our findings as the studies available for this meta-analysis were carried out exclusively in developed countries.

Correlations of fatigue in Danish patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis

Objective

To describe fatigue in relation to disease-specific and socioeconomic factors and to test possible correlations between fatigue and work impairment, quality of life, pain, sleep, depression, and physical functioning in people with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA).

Methods

A questionnaire-based cross-sectional survey collecting patient characteristics such as disease characteristics, socioeconomic factors and patient-reported outcomes (PROs) from patients with RA, PsA and axSpA in Denmark. PRO scales included the FACIT-Fatigue sub-scale, Work Productivity and Activity Impairment scale (WPAI), EuroQol (EQ-5D), Medical Outcomes Study Sleep Scale (MOS), Major Depression Inventory (MDI), and Health Assessment Questionnaire (HAQ). Respondents were recruited via routine visits to the outpatient rheumatology clinic; information on diagnosis, treatment and disease activity was collected from medical journals by trained nurses.

Results

487 patients participated in the study. Fatigue was more present in women, experienced patients, and patients who changed medication in the past 12 months, who were unemployed, who had less education, and who had lower household income. There was no statistically significant difference between mean fatigue in the three diagnostic groups (p = 0.08). Fatigue correlated with all included PROs (Pearson correlation coefficients, p<0.0001). Stratifying for diagnosis and adjusting for socioeconomic factors did not change the conclusion.

Conclusion

In a stable, representative group of patients with RA, PsA and axSpA, we found significant correlations between fatigue and work impairment, quality of life, pain, sleep, depression and physical functioning. Fatigue cannot be perceived as a single problem, but rather as a symptom that affects broadly.

The outcomes of bariatric surgery on rheumatoid arthritis disease activity: a prospective cohort study

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that primarily affects the joints. Overweight and obesity can aggravate disease activity and clinical outcome in patients with RA. However, the role of bariatric surgery in inducing weight loss in the treatment of RA has not been confirmed. In this 12-month prospective cohort study, RA patients with obesity who were referred to our hospital were included. Thirty-two patients were classified into the bariatric surgery group according to the patient’s decision after a comprehensive assessment of surgery indications, and 33 patients received only pharmacotherapy for RA. At the 12-month follow-up, the response rates of ACR20, ACR50 and ACR70 were 75.0% vs. 51.5%, 53.1% vs. 39.4% and 31.3% vs. 21.2% in the bariatric surgery and non-surgery groups, respectively (all p < 0.05); the mean DAS28-ESR, DAS28-CRP and cDAI scores were 1.5 ± 0.9 vs. 2.4 ± 1.4, 1.2 ± 0.9 vs. 2.2 ± 1.7 and 9.5 ± 6.8 vs. 15.8 ± 12.5, respectively, in surgical patients compared to non-surgical patients (all p < 0.05). Compared to baseline, after 12 months, a significant reduction was observed in the use of leflunomide, biological agents, combination treatments, and NSAIDs in both groups (p < 0.05 or p < 0.01). However, there was no difference in medication use between the 2 groups either at baseline or at the 12-month follow-up (all p > 0.05). Compared to non-surgical patients, in RA patients with obesity, weight loss after bariatric surgery was associated with lower disease activity. Medication tapering for RA in patients who underwent bariatric surgery was not superior to that in non-surgical patients.