Modifiable Disparities in Treatment for Rheumatoid Arthritis

描述（由申请人提供）：差异存在于卫生保健的各个方面，对健康和卫生服务的利用，包括药物治疗，有深远的影响。减少差距需要详细了解这些原因。虽然已经探索了许多慢性疾病的差异，但很少有工作集中在类风湿性关节炎（RA）上，类风湿性关节炎是最常见的全身性风湿性疾病，与死亡率增加，残疾和美国每年近200亿美元的医疗保健费用有关。类风湿关节炎药物治疗可以大大减少疼痛和残疾，建议包括所有患者的疾病缓解抗风湿药物（DMARD）。一些基于社区的研究表明，只有30- 60%的RA患者接受DMARD治疗，年龄较大，黑人种族和社会经济地位较低都与DMARD的使用不足有关。如果不更好地了解这些差异，干预措施就会受到严重阻碍。本研究的第一个目的是在全国代表性样本中检查RA治疗的地理，种族和社会经济差异。我们将使用具有代表性的大型全国性调查与相关的医疗保健索赔和/或地理编码的人口普查信息，以更清楚地了解DMARD使用的区域差异，以确定个人水平和社区水平的社会经济因素以及种族和民族是否发挥作用，并确定获得护理的机会如何影响处方。这些信息将使我们能够评估DMARD使用的变化有多少可以通过可修改的因素来解释。第二个目标是确定药物保险状态的积极和消极变化是否与DMARD用于RA的变化有关。研究支持这样一种论点，即保险的得失影响到保健服务所有方面的使用。我们将分析新的医疗保险D部分药物覆盖范围以及来自RA患者纵向队列中招募的年轻患者的信息，这些患者具有超过20年的数据，以评估药物保险如何影响获得用于RA的DMARD。第三个目标是确定与DMARDs治疗RA的差异相关的生态和卫生系统因素。经济脆弱的社区，如英语作为主要语言的比例低或房屋拥有率低，以及与风湿病学家和医院的距离更远，都可能对RA护理的差异产生负面影响。我们将与关联的利用和地理编码的数据与RA注册从几个全州范围内的医疗保险计划。在最后的目标，我们将调查患者，以确定的态度，信仰和知识，有助于在DMARD使用RA的差异。无论是先前的目标，也没有以前的研究纳入有关患者的态度，信仰和知识的RA治疗差异模型的信息。我们将有目的地对接受和未接受DMARD的RA患者进行抽样，以确定他们过去是否接受过DMARD，他们对这些药物的风险和益处的理解，以及他们在做出治疗决定时通常咨询的信息来源。公共卫生相关性：在这四个目标中收集的数据将回答有关RA护理差异的关键问题。同样，通过关注潜在的可改变的风险因素，收集的信息将直接指向减少DMARD使用差异的策略。

DESCRIPTION (provided by applicant): Disparities exist in all aspects of health care and have profound effects on health and the utilization of health services, including medications. Reducing disparities requires a detailed understanding of these causes. While disparities in many chronic conditions have been explored, little work has focused on rheumatoid arthritis (RA), the most common systemic rheumatic disease which is associated with increased mortality, disability and nearly 20 billion dollars in annual medical care costs in the US. RA drug treatment can substantially reduce pain and disability, and recommendations include disease-modifying anti-rheumatic drugs (DMARDs) for all patients. Several community-based studies document that only 30-60 percent of patients with RA receive DMARDs and that older age, black race and lower socioeconomic status all associate with under-use of DMARDs. Without a better understanding of these disparities, interventions are substantially hindered. The first aim of this research will examine geographic, ethnic, and socioeconomic disparities in RA treatment in nationally representative samples. We will use large representative national surveys with linked health care claims and/or geocoded Census information to gain a clearer picture of regional disparities in DMARD use, to determine whether both individual level and neighborhood level socioeconomic factors as well as and race and ethnicity play a role, and to identify how access to care affects prescribing. This information will allow us to assess how much of the variation in DMARD use can be explained by modifiable factors. The second aim will determine whether positive and negative changes in drug insurance status relate to changes in DMARD use for RA. Research supports the contention that gains and losses in insurance affect the use of all aspects of health services. We will analyze the new Medicare Part D drug coverage as well as information from younger patients enrolled in a longitudinal cohort of RA patients with over twenty years of data to assess how drug insurance affects access to DMARDs for RA. The third aim will identify ecologic and health system factors associated with disparities in the use of DMARDs for RA. Economically vulnerable neighborhoods, such as those with low rates of English as a primary language or low home ownership rates, and greater distance to rheumatologists and hospitals may all negatively impact disparities in RA care. We will work with linked utilization and geocoded data for enrollees with RA from several statewide health care insurance plans. In the final aim, we will survey patients to determine the attitudes, beliefs, and knowledge that contribute to disparities in DMARD use for RA. Neither the prior aims nor previous studies have incorporated information about patient's attitudes, beliefs, and knowledge into models of RA treatment disparities. We will purposefully sample patients with RA who do and do not receive DMARDs to determine whether they have been offered DMARDs in the past, their understanding of risks and benefits from these agents, and the usual sources of information they consult for making treatment decisions. PUBLIC HEALTH RELEVANCE: The data collected in these four aims will answer key questions about disparities in RA care. As well, by focusing on potentially modifiable risk factors, the information collected will point directly toward strategies for reducing disparities in DMARD use.