Patterns of glucocorticoid prescribing and provider-level variation in a commercially insured incident rheumatoid arthritis population: A retrospective cohort study

Beth I Wallace; Paul Lin; Neil Kamdar; Mohamed Noureldin; Rodney Hayward; David A Fox; Jeffrey R Curtis; Kenneth G Saag; Akbar K Waljee

doi:10.1016/j.semarthrit.2019.09.002

Patterns of glucocorticoid prescribing and provider-level variation in a commercially insured incident rheumatoid arthritis population: A retrospective cohort study

Semin Arthritis Rheum. 2020 Apr;50(2):228-236. doi: 10.1016/j.semarthrit.2019.09.002. Epub 2019 Sep 7.

Authors

Beth I Wallace¹, Paul Lin², Neil Kamdar³, Mohamed Noureldin², Rodney Hayward⁴, David A Fox⁵, Jeffrey R Curtis⁶, Kenneth G Saag⁶, Akbar K Waljee⁷

Affiliations

¹ VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Rheumatology, University of Michigan Medical School, 300 North Ingalls Street, Suite 7C27, Ann Arbor, MI 48109-5422, USA; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA. Electronic address: brennerb@med.umich.edu.
² Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA.
³ Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA.
⁴ VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
⁵ Department of Internal Medicine, Division of Rheumatology, University of Michigan Medical School, 300 North Ingalls Street, Suite 7C27, Ann Arbor, MI 48109-5422, USA.
⁶ Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁷ VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, MI, USA.

Abstract

Objective: Glucocorticoids are common in RA management despite an unfavorable, exposure-dependent risk profile impacted by patient and provider-level factors. Existing work describing glucocorticoid use in RA is not generalizable and does not adequately examine provider factors. We aim to describe how providers prescribe glucocorticoids to commercially insured, newly diagnosed RA patients in the United States.

Methods: This was a retrospective cohort study which used the national Optum© administrative database. We identified 9221 adults ages 18-65 with RA diagnosed 2010-2014. We assessed glucocorticoid dispensing 3 months pre-diagnosis through 12months post-diagnosis ("study period"), cumulatively stratified by calendar quarter and prescriber specialty (rheumatologist, primary care, other). We examined prescribing variation among individual rheumatologists by dividing quarterly distribution of per-patient dose and days' supply into quartiles.

Results: 6717 (72.8%) patients filled ≥1 glucocorticoid prescription during the study period. 2890 (31.3%) patients received ≥3 months' supply, with median (IQR) daily dose 10 (6.6) mg/day and days' supply 189 (143) days. 52.6% of patients received glucocorticoids 1-3 months post-diagnosis; 29.2% received glucocorticoids 10-12 months post-diagnosis. Among glucocorticoid users post-diagnosis, quarterly median daily dose and days' supply were consistently ≥10 mg/day and ≥30 days, respectively. Rheumatologists prescribed most glucocorticoids, with median per-quarter daily dose and days' supply 10 mg/day and 43-60 days. Individual rheumatologists' prescribing varied widely across all quarters.

Conclusion: Among commercially insured incident RA patients, receipt of ≥10 mg/day prednisone equivalent for months is common, typically prescribed by rheumatologists, and persists a year post-diagnosis in 29.2% of patients. Glucocorticoid prescribing varies widely across rheumatologists. Further work is warranted to identify provider factors explaining variation in glucocorticoid prescribing, and assess how these affect health outcomes.

Keywords: Arthritis; Glucocorticoid; Prescribing drugs.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Antirheumatic Agents / therapeutic use
Arthritis, Rheumatoid / drug therapy*
Databases, Factual
Female
Glucocorticoids / administration & dosage*
Glucocorticoids / adverse effects
Humans
Longitudinal Studies
Male
Middle Aged
Practice Patterns, Physicians' / statistics & numerical data*
Primary Health Care / methods
Primary Health Care / statistics & numerical data
Retrospective Studies
Rheumatology / methods
Rheumatology / statistics & numerical data
United States

Substances

Antirheumatic Agents
Glucocorticoids

Grants and funding

T32 AR007080/AR/NIAMS NIH HHS/United States