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Potential Determinants of Poor Disease Outcome in Socioeconomically Disadvantaged Patients with Rheumatoid Arthritis

To the Editor:

We read with interest the report by Suarez-Almazor and colleagues¹ on the disparities in the time to initiation of disease modifying antirheumatic drugs (DMARD) in patients with rheumatoid arthritis (RA) under public care as compared to those under private care, seen at rheumatology clinics in Texas. The authors reported that the median disease duration at the time of initial DMARD therapy was 1.5 years in the public care setting and 0.5 years in the private care setting (p < 0.0001) and that ethnicity (White vs Non-White) was more important than being under public care (surrogate marker of socioeconomic status) in determining delayed DMARD initiation. The authors conclude that "the potential effects of these disparities on longterm outcomes are unclear, but could be very detrimental in the light of the evidence supporting early onset of DMARD therapy for most patients." We have recently reported on the timing of DMARD in 359 subjects with RA, 196 public care and 163 private patients, seen in Johannesburg, South Africa². Our results differ from those reported by Suarez-Almazor. Moreover, we recorded not only the timing of DMARD initiation but also the Health Assessment Questionnaire (HAQ-DI)³, a central outcome variable in RA³, as well as lifestyle factors, disease activity and disease severity variables, comorbidities, and treatment characteristics². We therefore believe that our results are of potential interest in the present context. Further, the editorial by Madhok, et al accompanying the article by Suarez-Almazor is informative in the interpretation of our results⁴.

Only 11% of the South African population is Caucasian. Yet, 85% of our private care patients belonged to the latter ethnic group, as compared to only 13% of our public care patients with the majority of them being African (62%) and the remainder Asian (12%) or of mixed ancestry (12%)². As applied to the patients of Suarez-Almazor, being under public care reflected socioeconomic disadvantage². Tumor necrosis factor-α blockade therapy and leflunomide were not available in our public care clinic².

In contrast to Suarez-Almazor's study, the time to DMARD initiation was not significantly different between public care (1.5 yrs) and private care patients (2 yrs) in our study². However, as well documented in previous RA investigations and as further discussed by Madhok and colleagues⁴, we found that socioeconomic disadvantage was associated with more severe RA. Thus, current disease activity and disease severity scores (number of deformed joints) were substantially and significantly higher in public care patients as compared to private care patients. Being under public care was also associated with the comorbidities of obesity and tuberculosis. These differences in current and cumulative disease activity between public and private care patients were present despite overall equally intensive DMARD prescriptions in both settings. Finally, whereas adverse lifestyle factors contribute to socioeconomic health differences as alluded to by Madhok and colleagues⁴, our public care patients smoked and used alcohol less often than did our private care patients.

In contrast to the finding of Suarez-Almazor, et al, that ethnicity rather than socioeconomic disadvantage predicted the delay in DMARD initiation in multivariable analysis¹, we found that socioeconomic disadvantage rather than ethnicity predicted poor disease outcome (HAQ > 1)². As expected, current and cumulative disease activity were further independently associated with poor disease outcome. Suarez-Almazor and colleagues found that the time to glucocorticoid initiation was also more delayed in socioeconomically disadvantaged patients with RA. Although glucocorticoids may retard radiographic progression when used early in the course of RA¹, the longterm use of these agents in established RA is not supported by currently available evidence⁵. Of interest in this regard, prednisone therapy, which was used 2.6 times more frequently in the public care setting than in the private care setting, was independently associated with a HAQ > 1.

Studies that address differences in characteristics of patients with RA seen in public care versus those seen in private care settings have the potential to contribute to the understanding of poor disease outcome in this disease. Although recently reported evidence indicates the need for early DMARD therapy with its appropriate regular intensification in the case of ongoing disease activity in RA^4,6,7, we found a poorer disease outcome in socioeconomically disadvantaged patients despite a lack of difference in the time to DMARD initiation as well as in the overall prescription patterns of DMARD. Indeed, the potential causes of poor disease outcome in socioeconomically disadvantaged patients with RA are many, often interrelated and complex³. As a consequence of our findings and in view of recently reported evidence^4,6,7, in 2005, we established a refractory RA clinic in our public setting in which patients with marked ongoing disease activity are managed separately, seen at more regular intervals, and comprehensively assessed at each visit. Whether tighter disease activity control can be obtained in this manner and in this setting is currently being investigated.

AHMED SOLOMON, FCP(SA); BERENICE F. CHRISTIAN, FCP(SA), Department of Rheumatology, Johannesburg Hospital, University of the Witwatersrand, Johannesburg, South Africa; PATRICK H. DESSEIN, MD, FCP(SA), FRCP(London), PhD, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, University of the Witwatersrand and Rheumatology Unit, Milpark Hospital, P. O. Box 1012, Melville 2109, Johannesburg, South Africa. Address reprint requests to Dr. Dessein. E-mail: Dessein@telkomsa.net

REFERENCES

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2. Solomon A, Christian BF, Dessein PH, Stanwix AE. The need for tighter rheumatoid arthritis control in a South African public health care center. Semin Arthritis Rheum 2005;35:122-31. [MEDLINE]

3. Strand CV, Crawford B. Longterm treatment benefits are best reflected by patient reported outcomes. J Rheumatol 2007;34:2317-9. [MEDLINE]

4. Madhok R, Alcorn N, Capell HA. Physician...attorney of the poor. J Rheumatol 2007;34:2320-2. [MEDLINE]

5. Morrison E, Capell HA. Corticosteroids in the management of early and established rheumatoid disease. Rheumatology 2006;45:1058-61. [MEDLINE]

6. Grigor C, Capell H, Stirling A, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single blind randomized control trial. Lancet 2004;364:263-9. [MEDLINE]

7. Bakker MF, Jacobs JWG, Verstappen SMM, Bijlsma JW. Tight control in the treatment of rheumatoid arthritis: efficacy and feasibility. Ann Rheum Dis 2007;66 Suppl:56-60.