The underutilization of DMARD therapy likely lies in perceptual misconceptions among primary care and internal medicine physicians for elderly patients. “Unfortunately, front-line providers perceive that older patients are too old, frail, sick, to receive DMARDs,” says Dr. Solomon. Consequently, older patients with RA are not getting referred for rheumatology care.
Lack of exposure to DMARDs during medical training is a large contributor to perceptual biases in primary care regarding RA in older patients. “Primary care thinks DMARDs are too toxic, hard to monitor, and patients are too sick for these treatments because they’re not giving these drugs every day and are not familiar with the side effects,” he says. In a forthcoming survey about primary care providers, Dr. Solomon notes, a large number of primary care providers state that they will not prescribe a DMARD under any circumstances. Fortunately, many clinicians in primary care will do DMARD maintenance therapy if initiated by a specialist.
Drs. Schmajuk and Solomon recognize that closing the RA treatment gap requires going beyond the rheumatology community. “We don’t have a simple solution to this issue, but we have to think beyond our practice,” says Dr. Solomon.
Immediate next steps are two-fold for improving quality of care in patients age 65 and older. “First, educate internists and primary care doctors on the need for DMARDs, and not just corticosteroids or nonsteroidal antiinflammatory drugs, for patients with active rheumatoid arthritis,” says Dr. Schmajuk. “Second, encourage patients with active rheumatoid arthritis and their providers to seek care from a rheumatologist.”
A longer-term view towards solving the RA treatment gap is also needed given the impending rheumatologist shortage in next decade forecasted by the ACR’s U.S. Rheumatology Workforce Study.3 “Over the next decade, access for patients with rheumatoid arthritis to rheumatologists and appropriate care with DMARDs is going to get more challenging than even the current environment,” notes Dr. Solomon. “As rheumatologists, we’ll need to figure out better systems of care to safely prescribe DMARDs, where we co-manage patients with nonrheumatologists. We’ll need to work more closely with primary care since they are going to be front-line providers for these patients who are not going to all be able to get in and see rheumatologists.”
Dr. Solomon admits that, “fundamentally, it’s an overhaul of our healthcare systems.” In an admittedly daunting task, the first step will be identifying models that work. “Presently no evidenced-based models exist yet for improving DMARD use in a given community,” he says.
