Missed opportunities for treatment of inflammatory arthritis and factors associated with non-treatment: An observational cohort study in United States Veterans with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis

Abstract

ObjectiveTo identify factors associated with non-treatment with biologic and non-biologic disease modifying anti-rheumatic drugs (DMARDs) during the 12 months after initial inflammatory arthritis (IA) diagnosis. MethodsWe identified Veterans with incident IA diagnosed in 2007–2019. We assessed time to treatment with Kaplan-Meier curves. We identified associations between non-treatment and factors relating to patients, providers, and the health system with multivariate Generalized Estimation Equation (GEE) log-Poisson. Subgroup analyses included IA subtypes (rheumatoid arthritis [RA], psoriatic arthritis [PsA], and ankylosing spondylitis [AS]) and timeframes of the initial IA diagnosis (2007–11, 2012–15, and 2016–19). ResultsOf 18,318 study patients, 40.7 % did not receive treatment within 12 months after diagnosis. In all patients, factors associated with non-treatment included Black race (hazard ratio, 95 % confidence interval: 1.13, 1.08–1.19), Hispanic ethnicity (1.14, 1.07–1.22), Charlson Comorbidity Index ≥2, (1.15, 1.11–1.20), and opiate use (1.09, 1.05–1.13). Factors associated with higher frequency of DMARD treatment included married status (0.86, 0.81–0.91); erosion in joint imaging report (HR: 0.86, 0.81–0.91); female diagnosing provider (0.90, CI: 0.85–0.96), gender concordance between patient and provider (0.91, CI: 0.86–0.97), and diagnosing provider specialty of rheumatology (0.53, CI: 0.49–0.56). ConclusionA high proportion of Veterans with IA were not treated with a biologic or non-biologic DMARD within one year after their initial diagnosis. A wide range of factors were associated with non-treatment of IA that may represent missed opportunities for improving the quality of care through early initiation of DMARDs.