Peripheral Geographic District and Low Socioeconomic Status Are Associated With Decreased Access to Biologics in Patients With Rheumatoid Arthritis

Objective: Lack of insurance coverage, limited access to health services and lower socioeconomic status (SES) are contributors to inadequate utilization of biologic disease modifying anti-rheumatic drugs (bDMARD) in rheumatoid arthritis (RA). The broad national insurance coverage for bDMARDs in Israel provides a unique opportunity to study the impact of SES and geographical location without being biased by the limitation of insurance coverage. Methods: We identified RA patients using the International Classification of Disease 9th revised codes. “True” RA patients are defined as patients receiving conventional DMARDs, being positive for rheumatoid factor or anti-cyclic citrullinated peptide, or being diagnosed by a rheumatologist. We compared the four geographical districts with regard to drug survival times on first bDMARD, age at RA diagnosis and the mean number of bDMARDs per patient. Results: The cohort included 4268 “true” RA patients. Drug survival times on first bDMARD were shorter in northern (3.74 ± 4.77 years) and central districts (2.74 ± 4.87 years) compared to Jerusalem (5.46 ± 7.42 years) and southern districts (5.23 ± 6.21 years) (p < 0.001). Mean age at the time of RA diagnosis was significantly higher in the southern district (58.3 ± 17.7 years) compared to the northern (55.5 ± 15.7 years), central (53.0 ± 17.8 years) and Jerusalem districts (55.3 ± 18.8 years) (p = 0.014). Higher SES was associated with a higher number of bDMARDs per patient (2.3 ± 1.9, 2.1 ± 1.9 and 1.7 ± 2.9 for high, intermediate and low SES, respectively) (p = 0.031). Conclusion: Residence in the Israeli periphery and lower SES are associated with delayed and suboptimal diagnosis and management of RA. Equal resources should be allocated to the periphery and areas with lower SES.