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Abstract Number: 1058

Variation in DMARD Therapy Following Methotrexate Failure for Newly-Identified Rheumatoid Arthritis in a National Veterans Health Administration Cohort

John McDougall Jr.1,2, Cynthia Brandt3,4, Melissa Skanderson3, Joseph Goulet3 and Liana Fraenkel5, 1National Clinican Scholars Program, Yale School of Medicine, New Haven, CT, 2Dep't. of Rheumatology, Yale School of Medicine, New Haven, CT, 3Veterans Affairs Connecticut Healthcare System, West Haven, CT, 4Emergency Medicine, Yale School of Medicine, New Haven, CT, 5Rheumatology, Rheumatology, Yale University School of Medicine, New Haven, CT, New Haven, CT

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: Biologic agents, DMARDs and rheumatoid arthritis (RA)

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Session Information

Date: Monday, November 6, 2017

Title: Health Services Research Poster II: Osteoarthritis and Rheumatoid Arthritis

Session Type: ACR Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose:

Absent contraindications to conventional DMARD (cDMARD) use, the Veterans Administration (VA) requires a 3-month trial of 2 cDMARDs prior to the use of biologic DMARD (bDMARD), for active rheumatoid arthritis (RA). In this national VA study, we used a time-to-event analysis in cases of newly-identified RA to examine variation between VA Integrated Service Network (VISN) areas in prescriptions following MTX monotherapy.

Methods:

A previously validated, 3-part definition was used to identify patients with RA within the VA Musculoskeletal Disorder (MSD) cohort (N > 5 million, Jan 1, 2000-Dec 31, 2013). The date of the first VA DMARD prescription was used to define both RA diagnosis and RA cohort entry. To limit our analysis to newly-identified RA, we included patients with >1 year in the MSD cohort prior to RA diagnosis. To make our RA cohort as uniform as possible, we included only patients who first received a >90-day period of VA-prescribed MTX monotherapy. Kaplan Meier survival analysis and bivariate logistic regression were used to assess patient demographic and clinical data. After adjusting for significant predictor variables, we used a multivariate logistic regression to examine initial, non-MTX DMARD prescription by VISN.

Results:

A total of 4,823 patients (91% male, median age 64yrs, median observation time 3.91 yrs) met our inclusion criteria. All 21 VISN areas were represented (mean number of RA patients per VISN = 230 pts; range 88-488). Overall, 1,911 patients (40%) were prescribed only MTX monotherapy while observed in the RA cohort. Of the remaining patients who did receive a non-MTX DMARD, 748 (15%) went on to receive a bDMARD, whereas 2,164 (45%) received a cDMARD, as their initial, non-MTX DMARD prescription. The median interval between the first MTX prescription and initial, all non-MTX DMARD prescription was 1.13 years (IQR 0.56-2.25); a Kaplan Meier survival analysis did not show a significant difference between bDMARD and cDMARD interval prescription times (Kaplan Meier log rank p=0.94). Examining regional variation, 8 VISN areas were at statistically higher odds of receiving an initial bDMARD prescription, when compared to the VISN with lowest percentage bDMARD prescriptions (OR range 1.0-3.29, reference cDMARD prescription in VISN 23, see Figure 1).

Conclusion:

Following MTX monotherapy for newly-identified RA, we found a 3-fold variation by VISN in the prescription of biologic versus conventional DMARDs (see Figure 1; base 1.0 [VISN 23] in blue, highest 3.29 [VISN 22] in red). Further work is needed to assess the causes of these differences.



Disclosure: J. McDougall Jr., None; C. Brandt, None; M. Skanderson, None; J. Goulet, None; L. Fraenkel, None.

To cite this abstract in AMA style:

McDougall J Jr., Brandt C, Skanderson M, Goulet J, Fraenkel L. Variation in DMARD Therapy Following Methotrexate Failure for Newly-Identified Rheumatoid Arthritis in a National Veterans Health Administration Cohort [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/variation-in-dmard-therapy-following-methotrexate-failure-for-newly-identified-rheumatoid-arthritis-in-a-national-veterans-health-administration-cohort/. Accessed .
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