Background/Purpose: Recognizing health care disparities in Rheumatoid Arthritis is crucial to improving outcomes. This study analyzes factors contributing to RA care inequities.

Methods: We examined RA disease activity, treatment, and vaccine rates over 12 yearly periods, 2012-2023. Eligibility criteria included RA patients ≥18 years. Low Clinical Disease Activity Index (CDAI≤10), steroid use ≥3 months, DMARD use ≥6 months, and vaccine (pneumococcal, shingles, flu) rates were compared based on insurance types and gender. Generalized estimating equations regression models were used to analyze binomial/multinomial outcomes.

Results: Population included 24,469 patients, median age 63, white 96%, women 74%, RF+ 74%, anti-cyclic citrullinated peptide (CCP+) 28%, Medicare 49%, Medicaid 5%, and Commercial insurance 22%. Insurance type didn’t affect DMARD use: Commercial versus (vs) Medicare and Medicaid (Odds Ratio (OR) 0.98, 0.97, p=0.7936, p=0.8242), Medicaid vs Medicare (OR 1.01, p=0.9426) (Figure 1). More women used DMARDs than men (OR 1.22, p=0.0074) (Figure 2). Steroid use was higher with Medicaid than Medicare and Commercial patients (OR 1.25, 1.41, p=0.0128, p=0.0003) respectively (Figure 1), and higher in men than women until period 9 (p=0.0002) (Figure 2). Disease control was better with Medicare and Commercial than Medicaid patients (OR 2.39, 2.22, p=0.001 respectively) but worse over time for all insurances (70.34% to 59.14%, p< 0.0001) (Figure 1). Men started with lower rates of CDAI ≤10 than women in period 1 (62% vs 71%) but achieved greater low disease activity than women in periods 2-12 (68% vs 59% p=0.046) (Figure 2). Disease activity worsened post COVID-19 pandemic for both insurance and gender in period 9 (2020) to 12 (2023) (Figures 1,2). Vaccine rates were higher with Medicare than Commercial or Medicaid (Singles OR 2.51, 3.28 p< 0.0001), (Pneumococcal OR 2.31, 2.33 p=0.0001), (Flu OR 1.41, 2.59 p=0.0001) (Figure 3). Pneumococcal and flu vaccine rates declined over time for all insurances (69% to 58%, 72% to 52%, p=0.0185, p=0.0001 respectively) (Figure 3). Gender didn’t influence vaccine rates, but they all declined with time (p< 0.05) (Figure 3). The decline in vaccination trend was particularly worsened post COVID-19 (period 9-12) independent of insurance or gender (Figure 3). Comparing to national data, our vaccine rates were similar for flu (53-72% vs 61%) (Coca, Arth. Rheumatol.2018;70(9)) but superior for shingles (39-46% vs 19%) (Calabrese, Arth. Care Res.2020;72(3)), and pneumococcal (58-69% vs 43%) (Alvarez, Vaccine.2024;42(3)).

Conclusion: Insurance type, gender, and COVID-19 played a substantial role in RA care delivery. Higher vaccine rates were achieved with Medicare, however, an overall declining trend, worse post COVID-19, left a considerable gap in our RA patients. Men (period 1-9) and Medicaid patients used more steroids. Men used less DMARDs, while percent at low disease activity worsened for all patients over time. This may be due to a higher capture of elevated CDAI measures (requires an in person visit) during COVID-19 (when the sickest patients were seen in person). Recognizing the drivers of RA inequities provides us with the opportunity to use a targeted approach to improving care.

Figure 1. The Treatment Rates (DMARD ≥6 months, Steroids ≥3 months) and Disease Activity (Low CDAI ≤10) Assessment by Insurance Type

Figure 2. The Treatment Rates (DMARD ≥6 months, Prednisone ≥3 months) and Low Disease Activity (CDAI ≤10) Assessment by Gender

Figure 3. The Vaccine Rates (Shingles, Flu, and Pneumococcal) Assessment by Insurance types and Gender

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/insurance-gender-and-covid-19s-effects-on-health-inequity-in-rheumatoid-arthritis-a-12-year-long-population-assessment/