Gaps in care for rheumatoid arthritis: A population study

Objective. Treatment guidelines for rheumatoid arthritis (RA) now recommend early, aggressive, and persistent use of disease-modifying antirheumatic drugs (DMARDS) to prevent joint damage in all people with active inflammation, and evaluation by a rheumatologist, when possible. This research assesses whether care for RA, at a population level, is consistent with current treatment guidelines. Methods. Using administrative billing data from the Ministry of Health in 1996-2000, all prevalent RA cases in British Columbia, Canada were identified. Data were obtained on all medications and all provincially-funded health care services. Results. We identified 27,710 RA cases, yielding a prevalence rate of 0.76%, consistent with epidemiologic studies. DMARD use was inappropriately low. Only 43% of the entire RA cohort received a DMARD at least once over 5 years, and 35% over 2 years. When used, DMARDs were started in a timely fashion, but were not used consistently. Care by a rheumatologist increased DMARD use 31-fold. Yet, only 48% and 34% saw a rheumatologist over 5 and 2 years, respectively. DMARD use was significantly more frequent, persistent, and more often used as combination therapy with continuous rheumatologist care. DMARDs were used by 84% and 73%, 40%, and 10% of people followed by rheumatologists continuously and intermittently, internists, and family physicians, respectively (P < 0.001). NSAID use, physiotherapy, and orthopedic surgeries were similar across these 4 care groups. Conclusion. RA care in the British Columbia population was not consistent with current treatment guidelines. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed.