https://immattersacp.org/weekly/archives/2011/02/08/1.htm

Despite clear guidelines, rheumatoid arthritis prescriptions vary among Medicare managed care plans

Despite clear guidelines, rheumatoid arthritis prescriptions vary among Medicare managed care plansNew BPH guidelines address new drugs, watchful waiting, and when to try surgery


More than one-third of Medicare managed care enrollees seen for rheumatoid arthritis did not receive recommended treatment with disease-modifying antirheumatic drugs (DMARDs), a study found. Variations by as much as 70% exist among health plans, with age, sex, race, income and geography also influencing DMARD receipt.

The Healthcare Effectiveness Data and Information Set (HEDIS) introduced quality measures on DMARDs in 2005. In a study in the Feb. 2 Journal of the American Medical Association, researchers analyzed HEDIS data for 93,143 patients 65 years or older with at least two diagnoses of rheumatoid arthritis within a year, from 2005 to 2008. “Two diagnoses” were defined as “at least 2 face-to-face physician encounters with different dates of service in an ambulatory or nonacute patient setting during the measurement year with any diagnosis of [rheumatoid arthritis],” as determined by ICD-9 codes. The average age of patients was 74 years; 75% were women and 82% were white.

Overall performance on the HEDIS measure for rheumatoid arthritis in the study sample was 63%. In 2005, 59% of the sample received a DMARD, increasing to 67% in 2008. The largest difference in performance on the HEDIS rheumatoid arthritis measure was based on age. Participants 85 years and older were 30% less likely to receive DMARDs compared with patients 65 to 69 years old. The difference may be due to age bias, increased prevalence of comorbidities that may represent contraindications to DMARD use, patient preferences against DMARD receipt, or a milder or different clinical course among older patients, researchers speculated.

Other patients less likely to receive a DMARD included men, individuals identified by race as black or other, individuals with low personal income, residents of lower socioeconomic status ZIP codes, and individuals in the Middle and South Atlantic regions. Also, patients living in a health professional shortage area had a 3% lower rate.

In addition, patients enrolled in a for-profit health plan had a 4% lower rate of DMARD receipt compared with patients enrolled in a not-for-profit health plan, the authors wrote. Performance varied among health plans from 16% to 87%. Possible explanations for these differences include availability or accessibility of specialty care or differences in the ability of the health plan to appropriately identify patients in the numerator and denominator for the measure.

“Given the enormous individual and societal costs associated with rheumatoid arthritis, and increasing substantial evidence that DMARDs can reduce these costs, variations in DMARD receipt based on demographics, socioeconomic status, and geography are unacceptable,” the authors concluded. “Because optimizing DMARD use is the primary mechanism for decreasing the significant public health impact of rheumatoid arthritis in the United States, targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities.”