Naik Anisha, Baraff Aaron, Wysham Katherine D, Liew Jean W, England Bryant R, Roul Punyasha, George Michael, Baker Joshua F, Barton Jennifer L, Makris Una E, Kerr Gail, Cannon Grant W, Mikuls Ted R, Singh Namrata
VA Puget Sound Health Care System, Seattle, Washington.
VA Puget Sound Health Care System and University of Washington, Seattle.
Arthritis Care Res (Hoboken). 2025 Jan;77(1):23-29. doi: 10.1002/acr.25457. Epub 2024 Nov 28.
Racial and ethnic disparities in rheumatoid arthritis (RA) outcomes are well recognized. However, whether disparities in RA treatment selection and outcomes differ by urban versus rural residence, independent of race, have not been studied. Our objective was to evaluate whether biologic disease-modifying antirheumatic drug (bDMARD) initiation after methotrexate administration differs by rural versus urban residence among veterans with RA.
In this retrospective cohort study using national US Veterans Affairs (VA) databases, we identified adult patients with RA based on the presence of diagnostic codes and DMARD administration. We included patients receiving an initial prescription of methotrexate (index date) between 2005 and 2014, with data through 2016 used for follow-up. Urban-rural status was categorized using the Veteran Health Administration's Urban/Rural classification. Our primary outcome of interest was time to biologic initiation within two years of starting methotrexate. Multivariable Cox proportional hazards models were conducted adjusting for demographics, comorbidities, and rheumatoid factor or anti-cyclic citrullinated peptide positivity.
Among 17,395 veterans with RA (88% male, 42% with rural residence) fulfilling eligibility criteria, 3,259 (19%) initiated a biologic within the first two years of follow-up. In multivariable models, residence in an urban area was associated with a statistically significant higher biologic administration compared to rural areas (adjusted hazard ratio 1.10 [95% confidence interval 1.02-1.18]).
Our study found only modest differences in the initiation of biologic therapies among rural- versus urban-residing veterans with RA in the VA health care system. These findings suggest that disparities are not easily explained by rurality within the VA health care system.
类风湿关节炎（RA）治疗结果中的种族和民族差异已得到充分认识。然而，独立于种族之外，RA治疗选择和结果的差异是否因城市与农村居住地不同而有所不同，尚未得到研究。我们的目的是评估在患有RA的退伍军人中，甲氨蝶呤给药后生物性病情改善抗风湿药物（bDMARD）的起始使用情况是否因农村与城市居住地不同而存在差异。
在这项使用美国退伍军人事务部（VA）全国数据库的回顾性队列研究中，我们根据诊断代码和DMARD给药情况确定成年RA患者。我们纳入了在2005年至2014年间接受甲氨蝶呤初始处方（索引日期）的患者，并使用截至2016年的数据进行随访。城乡状况使用退伍军人健康管理局的城乡分类进行划分。我们感兴趣的主要结局是开始使用甲氨蝶呤后两年内开始使用生物制剂的时间。进行多变量Cox比例风险模型分析，对人口统计学、合并症以及类风湿因子或抗环瓜氨酸肽阳性进行校正。
在17395名符合资格标准的患有RA的退伍军人中（88%为男性，42%居住在农村），3259人（19%）在随访的前两年内开始使用生物制剂。在多变量模型中，与农村地区相比，城市地区居住与生物制剂给药在统计学上显著更高相关（校正风险比1.10 [95%置信区间1.02 - 1.18]）。
我们的研究发现，在VA医疗保健系统中，居住在农村和城市的患有RA的退伍军人在生物治疗起始方面仅存在适度差异。这些发现表明，在VA医疗保健系统中，差异不易用农村地区因素来解释。
