Leave No Joint Behind
“This was actually the very first year [ACR] did a global rheumatology summit. And in the summit, they had discussions about underserved areas where they can’t even get access to rheumatologists. … If one country is threatened, all of us are threatened,” said Kathryn Dao, MD, associate professor in the department of internal medicine’s division of rheumatology at UT Southwestern Medical Center in Dallas, in a video discussion about the conference on RheumNow. “Essentially, if we work together, we will help each other… [by] bringing rheumatology education to places where they don’t have good teachers, or professors or access to training. [Like the saying] ’no child [left] behind,’ [let’s] leave no joint behind,” she said.
4 Top Takeaways on Disparities in Rheumatic Disease Care
1. Differences in RA Disease and Physical Function Persist Across Racial and Ethnic Groups
What Was Discussed While previous studies have shown a significant disparity in care and outcomes for different races and ethnic groups in America, a new study looked at whether these divides have changed over time. The researchers found that despite steps being taken to correct these inequities and some improvement in scores, there is still a major gap in results. (The study only addressed outcomes and not issues related to access to care.) Why This Matters “These findings are also a reminder to clinicians that they should be mindful that their patients are coming from diverse racial and ethnic backgrounds, and may have different needs in order to achieve similar levels of success with advanced therapies. This study suggests that the rheumatology community needs to take active steps to address disparities in RA outcomes. Targeted, community-centered interventions that provide education and resources to promote early access to care are important, and can help ensure that all patients are given the best possible chance for disease remission,” said Jacqueline O’Brien, ScD, a clinical epidemiologist at CorEvitas in Houston, and the study’s coauthor. RELATED: #BlackHealthFacts and Statistics: A Knowledge Movement
2. It’s a Socioeconomic, Not Biological Problem
What Was Discussed As previously noted, patients in BIPOC (Black, Indigenous, and People of Color) communities with arthritis and other types of rheumatic disease tend to have less access to good care and worse outcomes than similar white patients. “Care access, including timely referral to rheumatology [doctors], timely DMARDs or biologic therapy, minimizing treatment disruption, and avoidance of unnecessary steroids all impact disease outcomes. Patients from traditionally marginalized groups may experience disruptions in each of these areas. We know untreated patients not only risk erosive joint disease, but also comorbidities including cardiovascular disease and hematologic malignancy, says Ashira Blazer, MD, assistant professor in the department of medicine at NYU Grossman School of Medicine in New York City. She urged practitioners and researchers to rethink how they perceive race. Panelist Iris Navarro-Millan, MD, MSPH, assistant professor of medicine at Weill Cornell Medicine and the Hospital for Special Surgery in New York City, called for more diversity in the work force, improving health literacy, and reducing barriers to care. Why This Matters “It’s important for patients and providers to understand that up to 80 percent of health outcomes are contingent upon the social determinants of health. Rheumatic diseases are no exceptions to this rule. This means that understanding the patient’s environment is critical to ensuring the best outcomes. Many social determinants of health can be addressed through partnerships with adjunct providers such as social workers, and patient needs should be assessed during clinical visits,” says Dr. Blazer. RELATED: Racism In Healthcare: Why Culturally Congruent Care Matters
3. Rashes, Skin Changes in People of Color Are Too Often Overlooked
What Was Discussed Dermatologic changes in people with darker skin often go undetected by doctors because they are not trained in what to look for. Lisa Zickuhr, MD, assistant professor of medicine within the division of rheumatology at Washington University School of Medicine in St. Louis, moderated a session in which researchers reviewed different rashes commonly encountered in rheumatology, their mimickers, and the differences in appearance between light and darker skin tones. Dr. Zickuhr said, “First, interface dermatitis appears [violet] or purple in darker skin tones. This contrasts with the pink appearance such rashes have in lighter skin tones. Second, the presence and location of scale can be a distinguishing factor between acute and subacute cutaneous lupus, active and inactive discoid lesions, and even fungal infections versus autoimmune skin diseases.” She adds that it is imperative that educators collaborate and pool resources, and increase exposure to rheumatic skin disease among patients of color in order to improve medical school training. RELATED: Too Many Doctors Are Misdiagnosing Disease on Skin of Color Why This Matters “Patients of color suffer worse outcomes than their white counterparts, a disparity that extends to patients with rheumatic disease. Cutaneous findings often help clinicians properly diagnose patients with rheumatic diseases and can be the clue that leads to early diagnosis, early treatment, and better disease outcomes. Therefore, it is essential that clinicians can properly identify and diagnose autoimmune skin disease in all patients, especially those of color. Patients sense clinical confidence and competence in their providers, and improving clinicians’ skills can improve patient outcomes as well as enhance patients’ trust in their providers and the medical system,” said Zickuhr. RELATED: New Data Reveals Disparities in Lupus Rates, Particularly for BIPOC Women
4. Without Awareness and Access, Care Is Subpar, or Nonexistent, in Poor Countries
What Was Discussed In 2012, there was only one rheumatologist in Ghana; neighboring countries did not fare much better, said Dzifa Ida Dey, MD, consultant physician and rheumatologist in the department of medicine and therapeutics of the Korle-bu Teaching Hospital and Lecturer at the University of Ghana School of Medicine and Dentistry in Accra, “There was lack of awareness about this among patients. … and a lack of knowledge, [and] diagnostic and management skills among health practitioners. … Medications were simply not available,” she said in a panel presentation. To tackle this massive inequity, Dr. Dey spearheaded the creation of The Rheumatology Initiative (TRI) to train and support physicians and researchers, create better systems of care, and seek government support. TRI also focuses on patient education and helps patients access medications. Why It Matters In Ghana, lupus is now on the standard treatment guidelines list and there has been a 25 percent drop in the price of some biologics. More important, TRI emphasizes leadership building leadership skills in program participants to help spread knowledge among healthcare workers. This program model can be recreated in other countries that lack basic rheumatology care. RELATED: Rheumatoid Arthritis Research: News You Can Use From ACR 2021
