Research has consistently demonstrated racial and ethnic disparities in rheumatoid arthritis (RA). For example, a large cohort of patients with RA (n=6008) in the United States showed higher levels of disease activity among Hispanic patients and lower rates of remission among African American patients compared with white patients. In addition, both groups had worse functional statuses compared with white patients.1

In another study published online in June 2019 in the Journal of Clinical Rheumatology, researchers at Rush University investigated ethnic and racial disparities among patients with RA who were treated at an academic outpatient rheumatology clinic. They reviewed the medical records of 152 newly diagnosed, drug-naive patients who identified as black (37%), white (35%), Hispanic (20%), or other (8%).2  

The results revealed a substantial gap between Hispanic patients and the other 3 groups, in terms of median time to first rheumatology visit after symptom onset (22.7 months vs 6-8 months; P =.01). No significant differences were observed among the groups for time to treatment initiation following the first rheumatology visit. The black and Hispanic groups showed significantly higher Routine Assessment of Patient Index Data (RAPID3) scores (P =.04) and higher erythrocyte sedimentation rates (P =.01) compared with the black and Hispanic groups.

Rheumatology Advisor interviewed one of the authors of the recent study, Isabel Castrejon, MD, PhD, assistant professor in the division of rheumatology at Rush University Medical Center, Chicago, Illinois, to learn more about these disparities and any potential solutions.

Rheumatology Advisor: What is known thus far about racial and ethnic disparities in RA treatment, and what do your recent findings add to our understanding of this issue?

Dr Castrejon: It has been previously recognized how health disparities and inequities disproportionately affect racial and ethnic minority groups with RA, suggesting that ethnic minorities and uninsured patients are at risk of deleterious outcomes as a result of delayed therapeutic onset. Untreated inflammation in joints leads to irreversible damage, pain, loss of function, work disability, poor quality of life, and decreased life expectancy. Many studies have documented that treatment of RA within the first few months of the initial symptoms often results in the control of inflammation, allowing many patients to lead normal lives.3 However, the interval from initial symptoms to treatment in most patients is usually longer than 4 months — the recommended timeframe to initiate treatment — and considerably longer in minority groups.

Thanks to awareness of rheumatologists worldwide, the delay to initiate treatment has been decreasing over time. However, our recent data still show a delay ranging from 6 to 8 months in white patients and black patients and about 22 months in Latinos, who are generally younger and have more disease severity than the other groups at their initial visit.2 Potential reasons for this delay may be the limited access to health services and a lack of awareness about the consequences of untreated RA in the Latino community, among others.

Rheumatology Advisor: What is needed to help close these gaps, including any recommendations for clinicians?

Dr Castrejon: Although different strategies have been developed to ensure that patients are referred as early as possible, the strategies showing higher efficacy in addressing delay and the ones that should be promoted are education programs for primary care physicians and other health professionals and the implementation of rapid access to services. Other options are screening and education programs in the community to address the delay specifically in minority groups, including Latino patients.

The prolonged delay to initiation of treatment is of particular concern in Latinos, who may be most vulnerable to the effects of the disease, since in many cases, their livelihood and employability are closely linked to their physical function. Although Latinos are the largest minority group in the United States (expected to increase to 28.6% by 20604), little information is available on RA in Latinos, since the majority of research primarily includes white patients. Strategies to improve early diagnosis in Latinos are a challenge, based on cultural and linguistic differences, health literacy status, and general access to care.

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Rheumatology Advisor: What are other relevant implications for clinicians? 

Dr Castrejon: As a result of our recent findings here at Rush University Medical Center, and to fill this critical gap in our understanding of patient delay, we have developed an early referral program to shorten the delay for Latino patients. Latino health events, organized in collaboration with community partners, including a nonprofit organization called the Medical Organization for Latino Advancement, will provide an opportunity to generate awareness about RA in the Latino community here in Chicago. Education and resources for early access to care will be provided in a bilingual and accessible environment.

We aim to make an impact on the quality of care for Latino patients with RA by:

· Encouraging timely access to treatments to prevent joint damage and decline in physical function

· Promoting awareness by engaging the community and partner Latino organizations

· Promoting self-management to prevent functional disability and the loss of employment

· Involving underrepresented, underserved Latinos individuals in medical research

We invite clinicians or other health professionals interested in this initiative to email us at EarlyArthritis@rush.edu for more information.

Rheumatology Advisor: What should be the focus of future research on this topic?

Dr Castrejon: More research is needed to clarify the potential effects of these disparities in long-term outcomes, which may be very detrimental in light of the evidence supporting early treatment for most patients. In addition, we need to identify causes for patient and referral delays, especially among Latinos with RA, which may help to develop specific strategies for this population addressing additional challenges such as level of education, health literacy, language barriers, insurance coverage, and cultural sensitivity, among others. As rheumatologists, we need to provide optimal care to our patients regardless of their social status, race, ethnicity, or gender, and this future research will definitely help in addressing these disparities. 

References

1. Greenberg JD, Spruill T, Shan Y, et al. Racial and ethnic disparities in disease activity in patients with rheumatoid arthritis. Am J Med. 2013;126(12):1089-1098.

2. Riad M, Dunham DP, Chua JR, et al. Health disparities among Hispanics with rheumatoid arthritis: delay in presentation to rheumatologists contributes to later diagnosis and treatment [published online June 18, 2019]. J Clin Rheumatol. doi:10.1097/RHU.0000000000001085

3. Raza K, Buckley CE, Salmon M, Buckley CD. Treating very early rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2006;20(5):849-863. doi:10.1016/j.berh.2006.05.005

4. Colby SL, Ortman JM. Projections of the Size and Composition of the US Population: 2014 to 2060. https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf. United States Census Bureau. Published March 2015. Accessed July 17, 2019.