Modifiable Disparities in Treatment for Rheumatoid Arthritis

说明(申请人提供)：在卫生保健的所有方面都存在差异，并对健康和包括药物在内的卫生服务的利用产生深远影响。缩小差距需要对这些原因有详细的了解。虽然人们研究了许多慢性疾病之间的差异，但很少有人关注类风湿性关节炎(RA)，这是一种最常见的系统性风湿病，与死亡率、残疾和美国每年近200亿美元的医疗费用增加有关。RA药物治疗可以大大减少疼痛和残疾，建议包括为所有患者使用疾病修改的抗风湿药物(DMARD)。几项基于社区的研究表明，只有30%-60%的RA患者患有DMARDS，年龄较大、黑人种族和较低的社会经济地位都与DMARDS的使用不足有关。如果不能更好地了解这些差异，干预工作就会受到很大阻碍。这项研究的第一个目的是在具有全国代表性的样本中检查类风湿性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性调查，将医疗保健索赔和/或地理编码的人口普查信息联系起来，以更清楚地了解DMARD使用的地区差异，确定个人层面和社区层面的社会经济因素以及种族和民族是否都在发挥作用，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使用中有多少变化可以用可修改的因素来解释。第二个目标将确定药品保险状况的积极和消极变化是否与DMARD用于RA的变化有关。研究支持这样一种观点，即保险的得失影响到卫生服务的所有方面的使用。我们将分析新的Medicare Part D药物覆盖范围，以及从具有超过20年数据的RA患者纵向队列中登记的年轻患者的信息，以评估药物保险如何影响RA获得DMARDS的机会。第三个目标将确定与类风湿关节炎DMARDS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率低或住房拥有率低的社区，以及距离风湿病医生和医院更远的社区，都可能对RA护理方面的差异产生负面影响。我们将使用来自几个全州医疗保险计划的RA参保人的链接利用和地理编码数据。在最终目标中，我们将对患者进行调查，以确定导致DMARD用于RA的差异的态度、信念和知识。先前的目标和先前的研究都没有将有关患者态度、信念和知识的信息纳入类风湿关节炎治疗差异的模型中。我们将有目的地对接受和不接受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好处的了解，以及他们为做出治疗决定而咨询的通常信息来源。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关节炎护理差异的关键问题。此外，通过将重点放在潜在的可修改的风险因素上，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.