title: Geographic Variation in the Quality and Cost of Care for Patients with Rheumatoid Arthritis.
abstract: BACKGROUND
  There is considerable push to improve value in health care by simultaneously increasing quality while lowering or containing costs. However, for diseases that are best treated with comparatively expensive treatments, such as rheumatoid arthritis (RA), there could be tension between these aims. In this study, we measured geographic variation in quality, access, and cost for patients with RA, a disease with effective but costly specialty treatments.
  
  
  OBJECTIVE
  To assess the geographic differences in the quality, access, and cost of care for patients with RA.
  
  
  METHODS
  Using large claims databases covering the period between 2008 and 2014, we measured quality of care metrics by metropolitan statistical areas (MSAs) for patients with RA. Quality measures included use of disease-modifying antirheumatic drugs (DMARDs) and tuberculosis (TB) screening before initiating biologic DMARD therapy. Access to care measures included measured detection and the share of patients with RA who visited a rheumatologist. Regression models were used to control for differences in patient demographics and health status across MSAs.
  
  
  RESULTS
  For the 501,376 patients diagnosed with RA, in the average MSA 64.1% of RA patients received a DMARD, and 29.6% of RA patients initiating a biologic DMARD appropriately received a TB screening. Only 17% (73/430) of MSAs comprised the top 2 Medicare Advantage star ratings for DMARD use. Measured detection was 0.59% (IQR = 0.47%-0.71%; CV = 0.355) on average, and 57.6% (IQR = 48%-69%; CV = 0.341) of RA patients visited a rheumatologist. MSAs with the highest DMARD use spent $26,724 (in 2015 U.S. dollars) annually treating patients with RA, $5,428 more (P < 0.001) than low DMARD-use MSAs, largely because of higher pharmacy cost ($5,090 vs. $7,610, P < 0.001). However, MSAs with higher DMARD use had lower RA-related inpatient cost ($1,890 vs. $2,342, P = 0.024).
  
  
  CONCLUSIONS
  There were significant geographic variations in the quality of care received by patients with RA, although quality was poor in most areas. Fewer than 1 in 5 MSAs could be considered high quality based on patient DMARD use. Access to specialist care may be an issue, since just over half of patients with RA visited a rheumatologist annually. Efforts to incentivize better quality of care holds promise in terms of unlocking value for patients, but for some diseases, this approach may result in higher costs.
  
  
  BACKGROUND
  The research reported in this manuscript was supported by AbbVie through consulting fees paid to Precision Health Economics (PHE). AbbVie and PHE collaborated to develop the study design and protocol. AbbVie and PHE participated in the interpretation of data, review, and approval of the manuscript. Shafrin and Shim are employed by PHE. Ganguli and Sanchez Gonzalez are employed by AbbVie. Seabury reports consulting fees from PHE. The results from this study were presented in poster form at the Academy of Managed Care Pharmacy's 2015 Annual Meeting and Expo; April 7-10, 2015; San Diego, California, and at the Academy of Managed Care Pharmacy's 2016 Annual Meeting and Expo; April 19-22, 2016; San Francisco, California. Study concept and design were contributed primarily by Shafrin, along with Ganguli and Seabury. Shafrin and Shim took the lead in data collection, and data interpretation was performed by Ganguli, Sanchez Gonzalez, Seabury, and Shafrin. The manuscript was written primarily by Shafrin, along with Shim and Seabury, and revised primarily by Ganguli, along with Sanchez Gonzalez and Seabury.
authors.affiliation: 1 Precision Health Economics, Los Angeles, California.
authors.forename: Jason
authors.initials: J
authors.lastname: Shafrin
authors.affiliation: 2 AbbVie, North Chicago, Illinois.
authors.forename: Arijit
authors.initials: A
authors.lastname: Ganguli
authors.affiliation: 2 AbbVie, North Chicago, Illinois.
authors.forename: Yuri Sanchez
authors.initials: YS
authors.lastname: Gonzalez
authors.affiliation: 1 Precision Health Economics, Los Angeles, California.
authors.forename: Jin Joo
authors.initials: JJ
authors.lastname: Shim
authors.affiliation: 3 Keck School of Medicine, University of Southern California, Los Angeles.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Seabury
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018501:Antirheumatic Agents / Q000191:economics / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000191:economics* / Q000453:epidemiology* / Q000628:therapy; D016208:Databases, Factual / Q000191:economics / Q000639:trends; D005260:Female; D017048:Health Care Costs / Q000639:trends*; D006801:Humans; D007345:Insurance Claim Review / Q000191:economics / Q000639:trends; D008297:Male; D006278:Medicare / Q000191:economics / Q000639:trends; D008875:Middle Aged; D011787:Quality of Health Care / Q000191:economics* / Q000592:standards / Q000639:trends*; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D018501:Antirheumatic Agents