Modifiable Disparities in Treatment for Rheumatoid Arthritis

描述（由申请人提供）：差距存在于卫生保健的各个方面，对健康和卫生服务（包括药物）的利用产生深远影响。减少不平等需要详细了解这些原因。虽然许多慢性疾病的差异已经被探索，但类风湿关节炎（RA）是最常见的系统性风湿性疾病，与死亡率和残疾增加以及美国每年近200亿美元的医疗保健费用相关。类风湿性关节炎的药物治疗可以大大减少疼痛和残疾，建议包括对所有患者使用改善疾病的抗风湿药（DMARDs）。一些以社区为基础的研究表明，只有30- 60%的RA患者接受dmard治疗，年龄较大、黑人和较低的社会经济地位都与dmard的使用不足有关。如果不能更好地了解这些差异，干预措施就会受到很大阻碍。本研究的第一个目的是在全国代表性样本中检查类风湿关节炎治疗中的地理、种族和社会经济差异。我们将使用具有代表性的大型全国调查，结合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使用的地区差异，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都起作用，并确定获得医疗服务如何影响处方。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。第二个目的将确定药物保险状态的阳性和阴性变化是否与RA使用DMARD的变化有关。研究支持这样一种观点，即保险的收益和损失影响到卫生服务的各个方面。我们将分析新的医疗保险D部分药物覆盖范围以及来自年龄较小的RA患者纵向队列的信息，这些患者的数据超过20年，以评估药物保险如何影响RA获得dmard的途径。第三个目标将确定与dmard治疗类风湿性关节炎使用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较低或房屋自有率较低的社区，以及距离风湿病学家和医院较远的社区，都可能对类风湿关节炎治疗的差异产生负面影响。我们将从几个州范围内的医疗保险计划中，为患有风湿性关节炎的登记者提供相关的利用和地理编码数据。在最终目的中，我们将调查患者，以确定导致DMARD用于RA的差异的态度、信念和知识。先前的目的和先前的研究都没有将患者的态度、信念和知识纳入RA治疗差异的模型中。我们将有目的地对接受和未接受DMARDs的RA患者进行抽样，以确定他们过去是否接受过DMARDs，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类风湿性关节炎护理差异的关键问题。此外，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.