Background/Purpose: Disparities in the initiation of disease modifying anti-rheumatic drugs (DMARDs) in ethnic minorities have been described in rheumatoid arthritis (RA) patients in the US (J Rheumatol 2007;34:2400-7). These disparities are of increased concern, as the early initiation of intensive treatment has become a cornerstone in RA management. Recognizing referral patterns and patient baseline characteristics may help to identify sources of delay. We aimed to evaluate disparities in referral and treatment initiation in RA patients at an academic rheumatology site.

Methods: We conducted a retrospective study of all RA patients (by ICD codes) seen at our rheumatology outpatient clinic between 2011/16. Among 542 RA patients, 152 (28%) received their initial evaluation by a Rheumatologist during this period, and were naive to any DMARD. We determined the duration between initial symptoms and first Rheumatology visit in months. Data extraction included referral source, demographics, and laboratory tests between others. A Multidimensional-Health Assessment Questionnaire, collected routinely in this setting, allowed us to calculate a RAPID3 score for disease activity assessment at baseline. Treatment information also was collected including time to initiate DMARD and prednisone use. Comparison between ethnic groups was performed using ANOVA or Kruskal-Wallis for differences between means or medians and Chi² for proportions.

Results: A total of 152 DMARD naive RA patients were seen; 35% were White, 37% Black, 20% Hispanic, and 8% were others. The median delay to first rheumatology visit ranged from 6 to 8 months for all patients groups, other than Hispanics, for whom delay was 22.7 months (p=0.01) (Table). In the Hispanic group, there was no difference in time to visit between those who selected Spanish as their preferred language and those who selected English. A higher percentage of White and Black patients were referred by PCPs relative to Hispanic patients, who mainly self-referred (p=0.01). Methotrexate was the most prescribed DMARD. No significant differences were seen in time to treatment initiation according to ethnicity. Disease activity by RAPID3 scores (p=0.04) and ESR (p=0.01) was significantly higher in Black and Hispanic groups, but other laboratory tests did not differ between groups.

Conclusion: RA patients are at risk of poorer outcomes as a consequence of delayed presentation to a rheumatologist leading to delay in treatment initiation. This study demonstrates a considerable delay in initial referral to a Rheumatologist, more pronounced among Hispanic patients, although they appear to have higher disease activity at presentation. Once seen in the clinic, initiation of DMARDs occurred within 1-month, regardless of ethnicity. More knowledge concerning delay in referral may help to develop better strategies for equitable access to effective therapies for all RA patients, regardless of ethnicity.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/prolonged-delay-in-presentation-to-rheumatologists-for-hispanic-patients-with-rheumatoid-arthritis-contributes-to-later-diagnosis-and-treatment/