Provider Specialty and the Use of Disease‐Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Older Adults in the 2005‐2016 National Ambulatory Medical Care Survey

Abstract

Objective We compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs). Methods In this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty. Results We identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003). Conclusion DMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.

Keep It in Mind: Assessing the Risk of Dementia in Patients With Rheumatoid Arthritis and Opportunities for Intervention

“…Although Kodishala et al 5 did not observe an association between DMARD use and dementia, they report an increased risk of dementia in patients with a phenotype suggestive of late-onset RA (ie, older age at RA diagnosis, large joint involvement, no erosive disease), a subgroup of patients who have been reported to receive lower rates of DMARDs (including bDMARDs). 20 Although the risks and benefits of DMARD use should be considered in each patient through a shared decision-making process, these observations may support another potential benefit of DMARD use in this patient population and may suggest that chronological age should not preclude the use of these therapies in older adults.…”

Initiation of Disease‐Modifying Antirheumatic Drugs in Older Medicare Beneficiaries With New Diagnosis of Late‐Onset Rheumatoid Arthritis

“…[9][10][11] In a single-state study of Medicaid and Medicare beneficiaries, only 15% to 30% of older adults received DMARDs, and older adults 75 years of age and older were two to three times less likely to receive DMARDs compared with those between the ages of 65 and 74. 11 This is in contrast to prior studies showing that on average, 30% to 44% of all patients with RA in nonspecialized ambulatory settings and more than 70% of those followed by rheumatologists receive DMARDs. 12 Although data are scarce and inconsistent, the few studies investigating efficacy of DMARDs have not revealed decreased effectiveness of csDMARDs or bDMARDs in older adults.…”

“…In recent years, the treatment paradigm of RA has evolved from traditional step‐up to more aggressive treat‐to‐target (T2T) strategies that promote early initiation, escalation, and combined use of conventional synthetic disease‐modifying antirheumatic drugs (csDMARDs) and biologic DMARDs (bDMARDs) 8 . Although DMARDs improve clinical, functional, and radiographic outcomes in patients with RA, older adults are less likely to receive treatment 9–11 . In a single‐state study of Medicaid and Medicare beneficiaries, only 15% to 30% of older adults received DMARDs, and older adults 75 years of age and older were two to three times less likely to receive DMARDs compared with those between the ages of 65 and 74 11 .…”

“…Although overall rates of adverse effects associated with DMARD use were comparable with that in younger adults, the use of bDMARDs was associated with two to three fold increase in risk of serious infectious complications for older adults 65 years of age or older 13,15 . In addition to DMARDs, glucocorticoids (GCs), alone or in combination with DMARDs, are commonly used to relieve symptoms of RA 11,16 . However, current clinical practice guidelines recommend limiting the use of GCs because of their adverse effects profile, including the risk of serious infections even with low doses 17 .…”

“… 8 Although DMARDs improve clinical, functional, and radiographic outcomes in patients with RA, older adults are less likely to receive treatment. 9 , 10 , 11 In a single‐state study of Medicaid and Medicare beneficiaries, only 15% to 30% of older adults received DMARDs, and older adults 75 years of age and older were two to three times less likely to receive DMARDs compared with those between the ages of 65 and 74. 11 This is in contrast to prior studies showing that on average, 30% to 44% of all patients with RA in nonspecialized ambulatory settings and more than 70% of those followed by rheumatologists receive DMARDs.…”