title: Relationships between driving distance, rheumatoid arthritis diagnosis, and disease-modifying antirheumatic drug receipt.
abstract: OBJECTIVE
  Disease-modifying antirheumatic drugs (DMARDs) are recommended for all patients with rheumatoid arthritis (RA). Some estimate that approximately one-half of patients with RA do not receive DMARDs. We hypothesized that patients with RA living farther from rheumatologists would be less likely to receive RA diagnoses and to receive DMARDs.
  
  
  METHODS
  US-based Medicare patients ages >65 years were study eligible. We calculated driving distance from patients' homes to the nearest rheumatologist. Using multivariable logistic regression, we assessed relationships between driving distance and RA diagnosis and between driving distance and DMARD receipt. In one set of analyses, distance was divided into quartiles: 0-2, 2.1-5, 5.1-15.9, and ≥16 miles. In a second set of analyses, we used predefined categories: 0-15, 15.1-30, 30.1-60, and >60 miles.
  
  
  RESULTS
  Among 59,426 Medicare beneficiaries, 918 had diagnosed RA. Compared to the first quartile, increased distance was associated with decreased odds of RA diagnosis (odds ratio [OR] 0.96 [95% confidence interval (95% CI) 0.80-1.16] in second quartile, OR 0.88 [95% CI 0.72-1.07] in third quartile, and OR 0.72 [95% CI 0.56-0.93] in fourth quartile; P < 0.01 for trend). Similar results were observed using predefined categories. Among those with RA, increased distance was associated with increased odds of DMARD receipt across quartiles (OR 1.15 [95% CI 1.06-1.25] in second quartile, OR 1.41 [95% CI 1.29-1.54] in third quartile, and OR 1.32 [95% CI 1.18-1.46] in fourth quartile; P = 0.001 for trend). There was no relationship between predefined categories and DMARD receipt (P = 0.45 for trend).
  
  
  CONCLUSIONS
  Increased driving distance to rheumatologists was associated with decreased odds of RA diagnosis. Among those with diagnosed RA, the odds of DMARD receipt rose as distance increased from <2 to 16 miles, but not beyond. Urban residents living closer to rheumatologists may have barriers to DMARD use besides geographic access.
authors.affiliation: Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Polinski
authors.forename: M Alan
authors.initials: MA
authors.lastname: Brookhart
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
authors.forename: Seoyoung C
authors.initials: SC
authors.lastname: Kim
authors.forename: Joyce
authors.initials: J
authors.lastname: Lii
authors.forename: Chris
authors.initials: C
authors.lastname: Tonner
authors.forename: Edward
authors.initials: E
authors.lastname: Yelin
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Solomon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis* / Q000188:drug therapy*; D001334:Automobile Driving / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D010824:Physicians' Offices; D012219:Rheumatology; D016896:Treatment Outcome; D014481:United States
chemical_list: D018501:Antirheumatic Agents