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Invited Commentary
December 6, 2019

Which Patients With Rheumatoid Arthritis Will Start Biologics, How Soon, and Why—Much to Learn From a Universal Coverage Setting

Author Affiliations
  • 1Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston
  • 2Arthritis Research Canada, Richmond, British Columbia, Canada
JAMA Netw Open. 2019;2(12):e1917065. doi:10.1001/jamanetworkopen.2019.17065

For patients newly diagnosed with rheumatoid arthritis (RA), rapid initiation of 1 or more disease-modifying antirheumatic drugs (DMARDs), usually a conventional synthetic DMARD (csDMARD) such as methotrexate, is now regarded as the standard of care.1 However, the threshold for initiating more costly biologic DMARD therapy is not as clear cut and has been influenced by sociodemographic, physician, and insurance coverage factors. To better understand these factors while eliminating confounding from differences in insurance coverage, Tatangelo et al2 examined sources of variation in the time to initiation of biologic DMARDs among a cohort of patients newly diagnosed with RA who were 67 years or older and had identical health and prescription medication coverage. Using linked administrative data from a universal, single-payer health care setting (ie, Ontario, Canada, the country’s most populous province), Tatangelo et al2 simultaneously assessed patient-level, prescriber-level, and region-level variation in the time from first csDMARD prescription to first biologic DMARD prescription. Unlike Medicare Part D in the United States, where coverage is administered by a variety of private insurers offering different plans, identical prescription drug coverage is provided by the provincial government to all residents of Ontario who are older than 65 years. In the study by Tatangelo et al,2 17 672 patients were followed up between 2002 and 2015, of whom 719 (4.1%) were prescribed a biologic DMARD. Patient-level factors associated with initiation of biologic DMARDs during follow-up included age, sex, immigrant status, disease duration, and distance from the patient’s own prescriber or from any rheumatologist.2 Controlling for patient-level characteristics, prescribers who graduated from medical school more recently or who practiced in areas with a greater supply of rheumatologists were more likely to initiate biologic DMARDs, while those practicing in rural areas were less likely.2 After adjusting for patient and prescriber characteristics as well as calendar year, Tatangelo et al2 found that 65% of the total variance in time to initiation of biologic DMARDs was associated with physician-level factors (ie, prescribing preferences), operationalized as the annual percentage of a physician’s biologic-naive patients with RA who initiated biologic DMARDs. A further 4.6% was owing to variance between regions and 30.4% to underlying variance.

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