Background/Purpose:  Only approximately 50% of rheumatoid arthritis (RA) patient with active disease receive care consistent with the American College of Rheumatology (ACR) recommendations for the use of biologic and nonbiologic disease modifying anti-rheumatic drugs (DMARDs).  Therefore we examined patient and provider factors associated with receipt of the recommended care using data from a multi-center observational registry within the United States (the Consortium of Rheumatology Researchers of North America: CORRONA). 

Methods:   We identified biologic naïve RA patients cared for within the CORRONA network between 12/08 and 12/11.  Initiation or dose escalation of biologic and nonbiologic DMARDs in response to active disease (using the Clinical Disease Activity Index) was assessed in comparison to the ACR recommendations.  The population was divided into two mutually exclusive cohorts: 1) methotrexate (MTX) only users; and 2) multiple non-biologic DMARD users.  We compared the characteristics of patients (age, gender, race/ethnicity, working status, insurance and RA disease characteristics) who received care consistent with the ACR recommendations and their treating providers (gender, years since medical school graduation, academic vs. private practice and region of the country [Northeast, South, Midwest and West]) to those who did not in the two cohorts with active disease using logistic regression adjusting for clustering of physicians and patients.

Results:  There were 5,196 patients who met inclusion criteria cared for by 191 providers at 86 practice sites.  Of the 991 MTX only users with active disease (moderate disease activity with a poor prognosis or high disease activity), 44% received care consistent with the treatment recommendations.  In adjusted analyses, patient characteristics including age 65 and older (OR 0.70; 95% CI 0.54-0.91), female gender (OR 1.47, 95% CI 1.10-1.98) and prednisone dose (OR 1.37, 95%CI 1.05-1.79) were associated with care practices while physician characteristics were not.  Among the 1209 multiple nonbiologic DMARD users with moderate or high disease activity, 48% received care consistent with the recommendations.  Patient age 65 and older (OR 0.73, 95% 0.57-0.94), residence in the South (OR 0.69, 95% CI 0.50-0.94) or Midwest (OR 0.73, 95% CI 0.54-0.99) and care by a private practice rheumatologist (OR 0.56, 95% CI 0.37-0.83) were associated with a reduced likelihood of receiving care consistent with the recommendations.  

Conclusion:   Compliance with the ACR treatment recommendations is influenced by both patient and provider characteristics.  Identification of these characteristics will help us identify which patients and providers to target for interventions to improve care.