RACIST AMERICA
Black patients with RA less likely to receive biologic, more likely to get glucocorticoids
ATLANTA -- A new study reveals that Black patients with rheumatoid arthritis (RA) were less likely to be prescribed a biologic treatment and more likely to use glucocorticoids, which carry a risk of serious long-term side effects. This study highlights ongoing racial disparities in the care of patients with rheumatic disease. Details of the study was shared at ACR Convergence, the ACR's annual meeting (RA is the most common type of autoimmune arthritis. It is caused when the immune system (the body's defense system) is not working properly. RA may cause pain and swelling in the joints as well as affect multiple organ systems such as the lung and eye. RA is treated with disease modifying anti rheumatic drugs, including biologics, to help stop joint pain and swelling, and also prevent joint damage. "
Racial disparities in access to care and effective treatment regimens are poorly understood in the RA population, but past research shows that non-white RA patients have a lower frequency of biologic use versus white patients, even when accounting for comparable disease activity and access to treatment. This new study looked at racial disparities in RA treatment and emergency department use in patients with RA at a single, tertiary academic center in Pennsylvania.
"With the explosion of effective therapies for rheumatoid arthritis, it is particularly important to make sure that we are treating patients in the best way possible," says the study's co-author, Michael George, MD, MSCE, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania. "Variability in practice, and disparities in treatment, suggest that there is room for significant improvement. We hope that this study will add to the existing literature about disparities in rheumatoid arthritis care-understanding why they exist and finding ways to address them are key to improving the health of patients with RA."
The study used electronic health record data from 1,831 patients with RA from 2010 to 2018. Patients had at least two RA diagnoses from a rheumatology outpatient encounter and at least one prescription of a disease-modifying antirheumatic drug (DMARD) during the follow-up period, or from their first to their last clinic visit. The researchers also measured patient demographic information, medication use and comorbidities at the baseline visit and at any point during the follow-up period.
The researchers then compared the differences in patient characteristics and visits between Black and white patients. Of the 1,831 patients in the study, 82% were female, 35% were Black, 54% were white and the mean age was 55. The average follow-up period for all patients was 6.97 years. Black patients were more likely to be older, have a higher body-mass index (BMI), were former or current smokers and had higher rates of cardiovascular disease and diabetes.
The researchers found racial disparities in how RA was treated with prednisone and conventional synthetic DMARD treatments used significantly more often in Black patients than whites: 79.3% of Black patients used prednisone compared to 69.1% of whites, and 96.7% of Black patients used a conventional DMARD compared to 93.5% of whites.
Additionally, white patients in the study were significantly more likely to use a biologic, a more advanced, expensive, and effective treatment for controlling RA disease activity and preventing joint damage. According to the data, 74% of whites and 67% of Blacks were prescribed a biologic drug. Black patients also had significantly more visits to the hospital emergency department (ED) over the eight-year period.
"This project supports prior work showing reduced use of biologics and a greater use of prednisone in patients who were Black - which could potentially mean worse outcomes or increased steroid side effects in this group," says Dr. George. "A key next step that many are working on is understanding the key drivers of these disparities - understanding why they exist (e.g., access to medications, insurance, patient-provider communication, health beliefs, etc.) is important so we know how to address these disparities."
ABSTRACT:
Characterization of Racial Disparities in Rheumatoid Arthritis Treatment Choice and Location of Care
Background/Purpose:
Racial disparities in access to care and treatment regimens exist but remain poorly characterized in the rheumatoid arthritis (RA) patient population. Previous studies using the Ethnic Minority RA Consortium (EMRAC) have demonstrated non-Caucasian RA patients have a lower frequency of biologic use versus Caucasian patients despite controlling for comparable disease activity and access to treatment. Here we explore longitudinal racial disparities in rheumatoid arthritis treatment and emergency department (ED) use in a single tertiary academic center.
Methods:
Structured de-identified data from 2010-2018 of patients who had at least two diagnoses of RA from a rheumatology outpatient encounter and at least one DMARD script during the follow-up period were extracted from the electronic health record of a single tertiary care center. Follow-up was measured from each patient's first visit to each patient's last visit within the 2010-2018 timeframe. Patient demographics were measured at the baseline visit, with medication use and comorbidities measured at baseline or at any point during follow-up. The average number of outpatient visits and ED visits per year (limited to ED visits within the health system) during follow-up were also measured. Differences in patient characteristics and visits were compared in patients who were Black versus white based on standard t-test and χ2 analysis.
Results:
A total of 1831 patients with rheumatoid arthritis were identified from 2010-2018. Baseline demographics were measured at each patient's first visit and include mean [SD] age, 55.05 [14.47] years; 1499 [81.87%] female; and 991 [54.12%] white. Average [SD] duration of follow-up for all patients was 6.97 [2.28] years. Comparing black (n=639) and white (n=991) patient demographics, significant findings include that black patients were more likely to be older, have higher BMI, former or current smoking status, and have higher rates of diabetes and cardiovascular disease (p< 0.0001). Prednisone and csDMARD use were significantly more frequent in black patients compared to white patients (79.3% vs 69.1% p< 0.0001; 96.7% vs 93.5%, p=0.005, respectively). Biologic use was significantly more common among white patients compared to black patients (white 74.3%, black 67.0% p=0.001). In terms of site of care delivery, black patients had significantly more ED visits, with a median 0.24 ED visits per patient per year versus 0.00 for white patients. A summary of the findings are shown in Table 1.
Conclusions:
Patients who were black were less likely to receive a biologic and more likely to use glucocorticoids. ED visit use was higher in black patients, which could be related to higher rates of comorbidities, although differences in geographic location could also influence whether patients visited an ED or saw non-rheumatology providers within or outside the health system. Further studies identifying drivers of racial disparities in access to care and outcomes are needed.
Black patients with lupus have three times higher risk of stroke
ATLANTA -- New research reveals that, in the U.S., Black patients with lupus have a threefold higher risk of stroke and a 24-fold higher risk of ischemic heart disease. The study also found several lupus-specific symptoms that predict stroke and IHD in these patients. Details of the study was presented at ACR Convergence, the American College Rheumatology's annual meeting (ABSTRACT #0433).
Systemic lupus erythematosus, also called lupus or SLE, is a chronic disease that causes systemic inflammation affecting multiple organs, such as the skin, joints, kidneys, the tissue lining the lungs (pleura), heart (pericardium) and brain. Many patients experience fatigue, weight loss and fever. The disease is more common among Black, Asian, and Native American people and tends to be worse in these groups.
Black people with lupus have a 19-fold higher occurrence of cardiovascular disease compared to other groups and have a disproportionately higher number of stroke-related events around the time of lupus diagnosis. Researchers wanted to know more about the specific risks and predictors of stroke and ischemic heart disease in Black people with lupus.
"The risk for developing cardiovascular disease is up to 52 times higher in patients with lupus, compared to patients without lupus. Black populations have three times higher risk to develop lupus, develop it at a significantly younger age and have more severe disease. However, most prior lupus and cardiovascular disease (CVD) studies were conducted in predominantly white cohorts, limiting the generalizability of the findings," says the study's co-author, Shivani Garg, MD, MS, Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. "It's important to quantify the risk, predictors and timing of stroke and ischemic heart disease in Black people with lupus in order to guide early CVD diagnosis and preventive interventions in this at-risk population." The study highlights the need for aggressive heart disease preventive care to reduce these racial disparities and improve lupus outcomes, particularly in recently diagnosed patients, she adds.
The researchers collected data from the Georgia Lupus Registry of lupus patients from Atlanta. They identified patients from 2002 to 2004 who met four or more of the ACR's SLE criteria or three criteria with a final lupus diagnosis by their own rheumatologist. They matched the patients to the Georgia Hospital Discharge Database and National Death Index from 2000 to 2013. Stroke and ischemic heart disease-related hospitalizations and deaths were based on hospital admission and death medical codes. Transient ischemic attacks were included in the stroke data, and myocardial infarction (heart attack) and angina were included in ischemic heart disease data. The researchers also examined symptoms that predicted strokes and ischemic heart disease. Of the 336 lupus patients included in the final study, 87% were female, 75% were Black, and the mean age at diagnosis was 40.
They found 38 stroke-related and 25 ischemic heart disease -related health events or deaths that occurred from two years before to 14 years after a lupus diagnosis. In the 11% of patients who had strokes, the mean age at first stroke was 48, and 78% of the strokes occurred in females. Ninety percent of the strokes occurred in Black patients. The peak number of strokes happened in the second year after lupus diagnosis. The study also showed that 8% of the patients had ischemic heart disease, and their mean age at diagnosis was 52. All the ischemic heart disease cases occurred in females, 96% occurred in Black patients and the peak number of cases occurred in the 14th year after diagnosis with lupus. All in all, the data showed that Black patients with lupus have a threefold higher stroke risk and a 24-fold higher ischemic heart disease risk than other groups.
What about potential predictors of stroke or ischemic heart disease? Discoid rash at the time of lupus diagnosis predicted a five-fold higher risk of stroke, while renal disorder at the time of lupus diagnosis predicted a two-fold higher stroke risk. Neither discoid rash nor renal disorder predicted ischemic heart disease, however. Strong predictors of ischemic heart disease were neurologic disorders (prior psychosis or seizure) and immunologic disorders (anti-DNA, anti-Sm, or antiphospholipid antibodies), but these did not predict strokes.
These findings highlight significant racial disparities in both stroke and ischemic heart disease among patients with lupus, says Dr. Garg.
"Our study increases awareness of higher risk, the timing of accelerated risk and disease presentations that contribute to higher risk of stroke and ischemic heart disease among Black patients with lupus. Such knowledge can help patients and providers look for and diagnose CVD events earlier and discuss starting preventive care to reduce their risk," says Dr. Garg. "Timely interventions could help reduce cardiovascular disparities in lupus and reduce CVD-related morbidity and mortality in young lupus patients, who are at relatively higher risk of premature CVD."
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About ACR Convergence
ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit https:/
About the American College of Rheumatology
The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.
ABSTRACT:
Racial Disparities and New SLE-Specific Predictors of Stroke and Ischemic Heart Disease in Patients with Lupus
Background/Purpose:
In the US, cardiovascular disease (CVD) is the leading cause of disparities in life expectancy between black and white populations. We recently reported a 19-fold higher occurrence of CVD in blacks with SLE compared to non-blacks and noted disproportionately high stroke-related events around the time of SLE diagnosis. This study measured the risk and predictors of stroke and ischemic heart disease (IHD) in a predominantly black, population-based, incident cohort.
Methods:
The Georgia Lupus Registry (GLR) is a population-based registry of SLE patients from Atlanta, Georgia. Incident patients in 2002-04 met ?4 ACR SLE criteria or 3 criteria with a final diagnosis of SLE by their board-certified rheumatologist. Patients were matched to the Georgia Hospital Discharge Database and National Death Index from 2000-13. Stroke- and IHD-related hospitalizations and deaths were classified by the first three admission or cause of death codes. Stroke also included transient ischemic attack, and IHD included myocardial infarction and angina. Predictors of strokes and IHD were examined using Cox proportional hazards models.
Results:
Among 336 incident SLE patients, 87% were female, 75% were black patient with a mean age at SLE diagnosis of 40 ± 17 years. There were 38 stroke-related and 25 IHD-related events or deaths, from the period 2 years before through 14 years after SLE diagnosis.
In the 11% with strokes, the mean age at first stroke was 48 years, with 78% occurring in females and 90% in blacks. The peak number of strokes occurred during the 2nd year after SLE diagnosis. We noted 8% had IHD, the mean age at first IHD was 52 years, with all occurring in females and 96% in blacks. The peak number of IHD occurred in the 14th year after SLE diagnosis.
Blacks had a 3-fold higher risk for stroke (HR 3.4, 95% CI 1.2-10, p 0.03) and a 24-fold higher risk for IHD (HR 24, 95% CI 3-206, p 0.004) (Table 1 & 2). Discoid rash at SLE diagnosis predicted a 5-fold (HR 4.6, 95% CI 1.7-13, p 0.003) and renal disorder predicted a 2-fold higher risk for stroke (HR 2.4, 95% CI 1.1-2.5, p 0.04) (Table 1). Neither impacted IHD (Table 2). Neurologic (HR 4.0, 95% CI 1.3-13, p 0.02) and immunologic disorder (HR 4.7, 95% CI 1.3-18, p 0.02) (Table 2) were strong predictors of IHD but not stroke.
Race stratified Cox proportional hazard models showed significantly accelerated stroke and IHD events in black compared to non-black patients (p ? 0.001) (Figure 1A & B).
Conclusions:
We found a 3-fold higher risk of stroke and 24-fold higher risk of IHD in blacks with SLE. We found different SLE-specific predictors of stroke and IHD: discoid rash and renal disorder predicted stroke, and neurologic and immunologic disorder strongly predicted IHD. This study provides unique insights on significantly different SLE-disease related predictors, timing and racial disparities in stroke compared to IHD in SLE. Hence, we highlight the need to consider different preventive strategies for stroke and IHD in SLE
About ACR Convergence
ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit https:/
About the American College of Rheumatology
The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.
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