Abstract
Prescribing the first biologic treatment for rheumatoid arthritis (RA) is an important decision for patients, their physicians, and payers, with considerable costs and clinical implications. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) have known effectiveness and safety profiles and are less expensive; therefore, determining the variables contributing to csDMARD treatment duration is an essential question for patients, physicians, and payers. To describe access to the first biologic DMARD prescription in a population of patients with RA and identical comprehensive health insurance coverage in Ontario, Canada, and to explore the associations of patient, prescriber, and geographic region with differences in time to first biologic prescription. This cohort study of incident patients with RA used administrative data with surveillance and patient-level data collected at yearly intervals. A total of 17 672 patients were included in the study; they were residents of Ontario, Canada, had an incident RA diagnosis at age 67 or older between 2002 and 2015, and received at least 1 csDMARD. Data were analyzed in November 2017. Patient variables were age, sex, disease duration, socioeconomic status, distance to care, and supply of care in the patient's area of residence. Prescriber covariates were year of graduation, specialty of practice, and supply of rheumatologic care in the patient's geographic region. Time from first csDMARD prescription to receipt of first biologic medication. Of 17 672 patients, 11 598 (65.6%) were women, and the mean (SD) age was 75.2 (5.8) years. Characteristics associated with longer time to receipt of a biologic prescription were older age (HR for every 5-year increase, 0.66; 95% CI, 0.62-0.71; P < .001), male sex (HR, 0.76; 95% CI, 0.66-0.89; P < .001), and distance to the nearest rheumatologist (HR per 10-km increase, 0.99; 95% CI, 0.98-0.99; P < .001). Prescribers were primarily rheumatologists (151 of 214 [70.6%]) and primary care physicians (26 of 214 [12.1%]). After adjusting for the number of patients eligible to receive biologic DMARDs, rheumatologists' preferences (ie, yearly prescription rates) for using biologic DMARDs increased over time, from 1.7% in 2001 to 4.9% in 2015. After adjusting for calendar year and patient-, prescriber-, and region-level characteristics, substantial variation between prescribers in rates of prescribing a first biologic DMARD were found (65% variance). This study found variation in time to receipt of first biologic DMARD after prescription of first csDMARD in a population with RA after adjustment for individual-level patient, prescriber, and geographic area covariates, despite identical universal health insurance coverage.
Highlights
In Canada, approximately 300 000 patients, or 1% of the population, are living with rheumatoid arthritis (RA).[1]
Characteristics associated with longer time to receipt of a biologic prescription were older age (HR for every 5-year increase, 0.66; 95% CI, 0.62-0.71; P < .001), male sex (HR, 0.76; 95% CI, 0.660.89; P < .001), and distance to the nearest rheumatologist (HR per 10-km increase, 0.99; 95% CI, 0.98-0.99; P < .001)
This study found variation in time to receipt of first biologic diseasemodifying antirheumatic drug (DMARD) after prescription of first csDMARD in a population with RA after adjustment for individuallevel patient, prescriber, and geographic area covariates, despite identical universal health insurance coverage
Summary
In Canada, approximately 300 000 patients, or 1% of the population, are living with rheumatoid arthritis (RA).[1]. Optimizing dose and treatment time with first-line csDMARDs saves health care resources, with a difference in costs of more than CaD$15 000 (US$11 460) annually, while preserving the clinical choice to escalate treatment to biologic therapy.[2,3,4] The ability to escalate to a biologic DMARD is critical; all clinical practice guidelines for RA recommend an adequate trial of csDMARDs before initiating a biologic medication.[2,3,4] Despite these recommendations, limited evidence informs clinicians and policy makers on the factors associated with earlier receipt of a biologic DMARD. This limitation is troubling because wide variations in access to and time to initiation of biologic therapy have been observed across health care jurisdictions.[5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20]
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