Racial, Ethnic, and Healthcare Disparities in Rheumatoid Arthritis

Abstract

Purpose of review

This review highlights the available data describing racial and ethnic health disparities among patients with rheumatoid arthritis (RA) in the United States from an epidemiological, disease activity and wider socioeconomic standpoint.

Recent findings

Despite centralized government initiatives to include more under-representative minority populations into research, many of the studies that examined RA still fail to include sizeable cohorts of races or ethnic groups other than Caucasian. Evidence is slowly mounting that individual, provider and system level barriers exist and contribute to unequal care that leads to poorer outcomes amongst patients with RA. As RA is a progressive disease, early treatment is crucial to delay functional decline – a narrow window for many minority patients who are disproportionality affected by disability.

Summary

In order to combat the inequality that exists amongst RA patients we must focus on why discrepancies exist on every level, system, physician, patient, and illness. Further research is needed to tease the complex interplay between race, SES, medical access and outcomes to explain the disparities found in RA.

Introduction

Health disparity in the United States (U.S.) has multiple dimensions and represent differences in health outcomes between different groups of society [1]. These are not limited to race and ethnicity, but can also be on the basis of sex, sexual identity, disability or age [1]. Working toward health equity in society requires that every aspect of society is involved in order to address inequalities between social groups so that they can attain the maximum level of health among all people [2]. Since 2010, health disparities have been addressed as a priority by the U.S. department of Health and Human services through the Healthy People plan [1].

Racial, ethnic, and access- related health disparities, are not the exception among patients with rheumatoid arthritis (RA); one of the most common inflammatory arthritis in the U.S. Nevertheless, disparities related to this disease specifically have not been studied in as much detail as in other conditions (e.g. lupus, diabetes) hence there is not a clear understanding about the magnitude of this problem or even the best way to intervene to address issues related to social determinants of health. This review summarizes the data available to date regarding racial and ethnic disparities among RA patients within the U.S.

Epidemiology

The prevalence of RA is approximately 1% in the U.S. population [3, 4]. For comparison, mean age adjusted prevalence rates suggest that North Africa, Middle East and Asia have relatively lower prevalence at 0.16%, North America and Western Europe at 0.44% with Australasia having the highest at 0.46% [5]. In the U.S., specific populations have been identified with higher rates of RA including the Pima and Pagago Indians of the American Indian population who have an age adjusted prevalence of 5.3% [6]. While it is traditionally reported that RA affects predominantly Caucasians, it is important to examine the proportion of individuals with RA within each racial/ethnic group. According to the 2019 U.S. Census Bureau, the total U.S. population was 328,239,523 with 76.3% Caucasian, 13.4% African American, 18.5% Hispanic or Latino, 5.9% Asian, 2.8% listed as two or more races and 0.2% Native American and other Pacific Islander [7].

To date, the majority of the epidemiologic studies, outcomes, and trials of patients with RA included primarily Caucasian patients or without racial information defined [3, 4, 8]. A recent systematic review of 240 RA RCTs estimated an over-representation of the Caucasian population ranging between 74.6% in 2010 to 97.0% in 2013 of researched participants [9]. There is little population based data regarding the specific IR and prevalence of RA among individuals who are African American or Hispanic. This lack of understanding of the epidemiology of RA by race and ethnicity limits our understanding of the burden of RA among different groups of our society and the health disparities amongst patients.

Disability and Disease Activity

Race itself appears to reveal a discrepancy between arthritis and related disability. Given the correlations between ethnicity, race, social economic class and even culturally this can be difficult to interpret [10].

The differences in reported disability could be related to differences in treatment for RA that could have led to disability. Still, once individuals with RA are disabled, they might still experience an additional disparity in the way that RA is treated. In a recent study among dual eligible (Medicare and Medicaid) beneficiaries of Social Security Disability Insurance (SSDI), individuals who filed for disability benefits before the retirement age of 65, showed significant differences in the use of bDMARDs amongst races [11]. African Americans were least likely to receive bDMARDs (49.3%) than Caucasians (53.3%) while Hispanics were more likely to receive bDMARDs (60.9%) [11]. These differences persisted after controlling for social determinants of health [11]. Disability in RA has led to high opioid prescription with more than 66% of SSDI beneficiaries to receive chronic opioids [11]. This proportion was not different between African Americans and Caucasians beneficiaries of the SSDI by 2014. This data suggest that early disability can result in over-reliance on opioids, likely given to high level of disability in a group of patients who were to begin with, highly vulnerable [11].

There are several studies that examined RA disease activity by race and ethnicity. Greenberg et. al. analyzed data from 6008 patients across community-based rheumatology clinics over a 5-year period in a cross sectional study. While there was improvement in disease activity across all racial groups, there were only small differences noted in CDAI scores between Caucasian 12.38 (11.36–13.4), African Americans 13.75 (12.39–15.1, p=0.007) and Hispanic patients 13.01 (11.68–14.34, p=0.179) in an adjusted model accounting for practice setting, treatments and patient sociodemographic factors [12]. In another cross sectional study focused on one academic center practice, African-Americans patients had increased DAS scores than Caucasians (5.5 ± 1.3 vs 4.3 ± 1.4; p <0.001) and HAQ (1.5 ± 0.8 vs 0.9 ± 0.7; p < 0.001) however, after accounting for socioeconomic, demographic and behavioral influences, race was not independently associated with the reported differences. Hence, to date, there is little data to support that individuals from a specific racial or ethnic group have more aggressive or higher diseases activity in RA [13, 14].

Jordan et al analyzed 100 female patients with RA and found that African Americans had less physical activity and more negative affect compared to their Caucasian counterparts despite no difference in pain severity. They found that the two groups used different psychological coping strategies with Caucasian patients more likely to ignore pain whilst African Americans patients turned to praying and hoping. Regardless of racial background, coping statements better predicted pain control suggesting that racial differences in coping strategies may contribute to reported differences [15]. Given the history and racism that African Americans and other minorities encountered in the health care system and in their communities, these coping mechanisms could have been shaped by their experiences with unequal treatment and racism that Caucasian individuals did not experience. This issue constitutes a problem that is not only limited to the health care system, but to the political system and how our society addresses inequality within its members.

SES/Access

A cross sectional study comparing a cohort of 4730 RA patients found that Caucasian patients, despite having a longer disease course had better global health scores and less pain [16]. Level of education attainment, duration of RA diagnosis and number of other co-morbidities were found to impact the pain ratings of Hispanic and African American patients [16]. There is convincing data across the world that lower SES (measured in different ways such as gross income, occupation, educational level and area of residence) has been linked to worse disease in RA patients, from disease activity, pain and disability [17–19]. Growing evidence has suggested that low SES even in childhood has a statistically significant trend (p<0.0001) of increasing the risk of development of RA; food insecurity (OR=1.5), young maternal age (<20 vs 20–34 years; OR=1.7) and childhood household education (<12 years vs college degree; OR=1.7; 95%) [20].

Schmajuk et al looked at 93,143 Medicare enrolled patients with RA and found significant correlations of DMARD use with socioeconomic factors. Living in an area of low SES, having low personal income (defined by needing state assistance for their Medicare Part B), male gender and African Americans race were all associated with a lower likelihood of being prescribed a DMARD [21]. As early treatment is beneficial for earlier remission, prevention of joint damage and disease related disability [22–24], it stands to reason that minorities without equitable access to care will accrue and be exposed to longer uncontrolled disease before therapy and therefore have poorer prognosis and remission rates.

Kerr et al compared the treatments of 2899 patients in the Veteran Affairs Rheumatoid Arthritis Registry (VARA) in the VA healthcare system (akin to a form of Universal Healthcare in the U.S.) and patients in the Ethnic Minority Rheumatoid Arthritis Consortium (EMRAC) where patients were part of varied health care systems. Notably, in the VARA cohort, there was no difference in biologic use between racial groups whereas EMARAC Caucasian patients had a higher odds ratio of 1.66 of receiving biologics compared to their non-Caucasian counterparts [25].

In a longitudinal observational study of 8,545 patients with RA, 43.6% noted difficulties paying out of pocket medical expenses. Those who had the greatest difficulty with healthcare costs were more likely to be on social security disability (33.9% vs 10.1%), be a minority race (10.3% vs 5.1%), have worse HAQ Scores (1.5 vs 0.9), higher co-morbidity index (2.5 vs 1.6), less likely to be a college graduate (20.3% vs 36.1%) and at the poverty level defined by Health and Human Services poverty guidelines (51.3% vs 12.3%) compared to those who reported “no difficulty” with medical costs. Patients most at financial risk were also those disproportionately affected those with the most severe disease and twice as likely to be a racial minority [26]. This may go some way to attribution of reduced treatment rates and access to effective therapies in this most vulnerable patient group. In addition, out of pocket costs have been shown to negatively impact adherence to medications in RA [27] and represent another barrier to those in lower SES which are made disproportionately of minority populations especially as they are almost twice as likely as Caucasian patients to be work-disabled [28].

System Level Disparities

Barton et al examined a diverse racial and immigrant population served by the same rheumatologists that worked at both a University and public based clinic [29]. This study found that Caucasian, English speaking and non-immigrant patients had lower DAS-28 and HAQ at a University setting only [29]. Notably, these differences were still present after adjustment for medication use suggesting that therapies alone did not account for the discrepancies but instead suggests the presence of a health disparity on the basis of clinic-level differences. Clinic-level differences could contribute to the health disparities observed in the patients with RA such as variation in time to initial rheumatology care and access to treatment [29].

Looking at two affiliate rheumatology clinics within one medical school, Suarez-Almazor et al compared their African American, Hispanic and Caucasian RA patients and found that non-Caucasian patients were more likely to be in a public rather than private clinic (83% vs 18%) and wait significantly longer before being started on DMARD therapy (median of 7 year vs 1 years) [30]. In patients with relatively early disease (<5 years), more Caucasian than non-Caucasian patients had already tried some form of DMARD prior to their index visit (64% vs 32%) [30]. These findings suggest intrinsic biases, which prevent the same level of access and care to racial minorities, are a crucial barrier in RA where early treatment can prevent long term joint damage [22–24].

As medicine moves towards an evidence based approach, it is important to reflect upon the long standing problem to recruit representative populations into research studies. The data and results they generate help guide societal guidelines and standards of practice especially as it is often the underserved minorities and often those in lower SES brackets that miss out on only research opportunities and potential future benefit. Notably, most large-scale studies of RA have been performed in Western nations, which skews identification of risk factors. Despite making up almost 41% of the US population, racial minorities only represented 16% of the RA population for RCTs [9]. Concerningly, despite efforts to increase awareness and participation from both researchers and patients, there hasn’t been an obvious improvement of minority representation over the ten year period studied (2008 to 2018) [9].

Given the differences and burden of disease on non-Caucasian populations delineated in this article, it is imperative that we better understand why discrepancies exist on every level, system, physician, patient, and illness level, if we are to fix the problem. This will require us to revisit the policies that contributed to bring us and our health care system to this unequal state to begin with, so we can right this wrong.

Article summary.

• RA research continues to predominantly focus on Caucasian populations leaving many questions such as epidemiology, disease course and outcomes unanswered in racial minority patients.

• Evidence is mounting that the differences observed between RA in racial groups can be attributed to non-biological factors.

• Socioeconomic status, differences in therapeutic prescriptions and access to healthcare reveal significant health disparities which must be addressed to provide equitable healthcare for all patients with RA.