title: Population Variations in Rheumatoid Arthritis Treatment and Outcomes, Northern California, 1998-2009.
abstract: OBJECTIVE
  To assess variations in rheumatoid arthritis treatment and outcomes at the community level from 1998 through 2009.
  
  
  METHODS
  The study used computerized data from 16 Kaiser Permanente Northern California Medical Centers. Mixed modeling was used to assess patterns across time and clinic. The analysis accounted for patient demographics, clustering of patients within Medical Centers, and repeated measures of patients over time. The metric used to measure drug use, months of use per patient per year, included both users and nonusers in the denominator, to account for both prevalence and duration of use.
  
  
  RESULTS
  Assessment was performed of 28,601 patients with rheumatoid arthritis, with all levels of severity. From 1998 through 2009, methotrexate use doubled in the typical patient to include 23% of the time they were observed; sulfasalazine and hydrochloroquine use declined. By 2008 through 2009, leflunomide and antitumor necrosis factor agents were used by the typical patient 4% and 9% of the time, respectively. Between 1998 and 2009, disease-modifying antirheumatic drug use increased in the typical patient from 38% to 63% of the time, and oral prednisone use declined from 23% to 15% of the time, whereas opioid use initially rose but then fell to 23% of the time. No variations over time were observed for the rate of hospitalized pneumonia or opportunistic infection. Variation across clinics, measured by the difference in drug use between clinics at the 75th and 25th percentiles, was lowest for opioids (25% vs 20% of the time) and greatest for infliximab (< 1% to 3%).
  
  
  CONCLUSIONS
  Increased use of disease-modifying antirheumatic drugs and declines in prednisone are encouraging. Opioid use may need intervention.
authors.affiliation: Research Scientist for the Division of Research in Oakland, CA. lisa.herrinton@kp.org.
authors.forename: Lisa J
authors.initials: LJ
authors.lastname: Herrinton
authors.affiliation: Associate Professor in the Department of Medicine at the University of Massachusetts Medical School in Worcester. leslie.harrold@umassmed.edu.
authors.forename: Leslie
authors.initials: L
authors.lastname: Harrold
authors.affiliation: Data Analyst in Clinical Education for the American Academy of Ophthalmology in San Francisco, CA. andyc298@yahoo.com.
authors.forename: Craig
authors.initials: C
authors.lastname: Salman
authors.affiliation: Senior Data Consultant for the Division of Research in Oakland, CA. liyan.liu@kp.org.
authors.forename: Liyan
authors.initials: L
authors.lastname: Liu
authors.affiliation: Rheumatologist at the Richmond Medical Center in CA. robert.goldfien@kp.org.
authors.forename: Robert
authors.initials: R
authors.lastname: Goldfien
authors.affiliation: Dermatologist and Research Scientist at Massachusetts General Hospital in Boston. masgari@partners.org.
authors.forename: Maryam
authors.initials: M
authors.lastname: Asgari
authors.affiliation: Dermatologist at the University of Pennsylvania in Philadelphia. joel.gelfand@uphs.upenn.edu.
authors.forename: Joel M
authors.initials: JM
authors.lastname: Gelfand
authors.affiliation: Director of Dermatology Research for the Department of Dermatology at the Los Angeles Medical Center in CA. jashin.j.wu@kp.org.
authors.forename: Jashin J
authors.initials: JJ
authors.lastname: Wu
authors.affiliation: Associate Professor of Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama in Birmingham. jeffrey.curtis@ccc.uab.edu.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D002140:California; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D055815:Young Adult