Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.

DMARD Use for Rheumatoid Arthritis as Reported in the National Ambulatory Medical Care Survey, 19962007.

Solomon4,  Daniel Hal, Ayanian3,  John, Brookhart6,  M. Alan, Schneeweiss2,  Sebastian, Shaykevich2,  Tamara, Yelin5,  Edward H., Katz1,  Jeffrey N.

Brigham & Womens Hosp, Boston, MA
Brigham and Women's Hospital
Brigham and Women's Hospital, Harvard Medical School
Brigham and Womens Hospital, Boston, MA
University of California, San Francisco, CA
University of North Caroline


There is broad agreement on the value of disease modifying anti-rheumatic drug (DMARD) treatment for rheumatoid arthritis (RA). In fact, a DMARD prescription for patients with RA has become a quality measure for various US-based health insurance programs. There are few population-based estimates of the rates of DMARD use for RA. We studied correlates of DMARD use in a large nationally representative US sample.


The study database consisted of visits in the US National Ambulatory Medical Care Survey (NAMCS), 1996–2007. Visits for RA were defined based on diagnosis codes reported by the providers. Providers list all medications, up to 8, used by the patient. Medication lists were checked for DMARDs, synthetic or biologic. Unadjusted and adjusted risk ratios were calculated to assess associations between patient and provider characteristics and receipt of any DMARD, as well as a biologic DMARD. All models accounted for the sampling design of NAMCS, using Rlogist in SUDAAN.


From the 317,416 visits recorded in NAMCS over the study period, we identified 859 (0.3%) visits associated with an RA diagnosis. 404 (47%) of these visits had a DMARD noted in the medication list—273 of 377 (72%) visits to rheumatologists and 131 of 482 (27%) to non-rheumatologists. Nine percent of RA visits had a biologic DMARD noted. There was no significant trend towards improved DMARD use rates over the 12 year study period. In adjusted models, black race was associated with reduced DMARD use and use of more medications was associated with increased DMARD use (see Table). Visits to non-rheumatologists were associated with a 60% reduction in DMARD use and a 50% reduction for biologic DMARDs.

Table: Risk Ratios for DMARD use in the National Ambulatory Medical Care Survey, 1 996–2007

 Any DMARD* use, risk ratio (95% CI)Biologic DMARD use, risk ratio (95% CI)
 Model 1Model 2Model 3Model 1Model 2Model 3
  65+ 1.01.0 1.001.0
  45–64y 1.3 (1.1–1.5)1.1 (0.9–1.4) 1.4 (1.1–1.7)1.2 (1.0–1.4)
  0–44y 1.3 (1.0–1.6)1.1 (1.0–1.3) 1.5 (1.1–1.8)1.3 (1.0–1.6)
  Male 1.01.0 1.01.0
  Female 0.9 (0.8–1.1)0.9 (0.8–1.1) 0.9 (0.8–1.2)1.0 (0.8–1.2)
  White non-hispanic1.
  Hispanic1.1 (0.9–1.4)1.1 (0.8–1.4)1.1 (0.9–1.4)1.1 (0.9–1.4)1.0 (0.8–1.4)1.1 (0.9–1.3)
  Black0.7 (0.4–1.1)0.6 (0.4–1.0)0.7 (0.5–1.0)0.7 (0.4–1.2)0.6 (0.4–1.1)0.7 (0.5–1.1)
  Other race non-hispanic0.9 (0.5–1.5)0.8 (0.5–1.4)1.2 (0.9–1.6)1.1 (0.9–1.6)0.8 (0.4–1.4)1.1 (0.8–1.6)
# of non-DMARD drugs      
  Zero 1.001.00 1.001.00
  1-2 1.6 (1.2–2.3)1.4 (1.1–1.9) 1.5 (1.0–2.1)1.3 (1.0–1.8)
  3+ 1.9 (1.4–2.7)1.8 (1.4–2.4) 1.8 (1.2–2.5)1.7 (1.3–2.3)
  Yes  1.00  1.00
  No  0.4 (0.3–0.5)  0.5 (0.4–0.6)
*Any DMARD includes methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, cyclosporine, gold preparations, D-penicillamine, azathioprine, etanercept, adalienumab, infliximab, rituximab, abatacept, anakinra. Model 1 only includes race/ethnicity and calendar year of NAMCS visit. Model 2 also includes age, gender, and number of drugs. Model 3 includes all of Model 2 variables and rheumatologist.


While there is likely misclassification of some visits, the use rate for DMARDs for RA was sub-optimal as reported in NAMCS over the 12-year study period. A visit to a rheumatologist was the most important correlate of DMARD use. Race/ethnicity remained associated with DMARD use after full adjustment. Interventions to improve DMARD use should target improving access to rheumatic disease specialists and identifying and overcoming barriers to DMARD use faced by Black patients.

To cite this abstract, please use the following information:
Solomon, Daniel Hal, Ayanian, John, Brookhart, M. Alan, Schneeweiss, Sebastian, Shaykevich, Tamara, Yelin, Edward H., et al; DMARD Use for Rheumatoid Arthritis as Reported in the National Ambulatory Medical Care Survey, 19962007. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :60
DOI: 10.1002/art.27829

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