Health Disparities Among Hispanics With Rheumatoid Arthritis: Delay in Presentation to Rheumatologists Contributes to Later Diagnosis and Treatment

Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature

OBJECTIVE

Diagnostic delay is a pervasive patient safety problem that disproportionately affects historically underserved populations. We aim to systematically examine and synthesise published qualitative studies on patient experiences with diagnostic delay among historically underserved racial and ethnic populations.

DATA SOURCES

PubMed.

ELIGIBILITY CRITERIA

Primary qualitative studies detailing patient or caregiver-reported accounts of delay in the diagnosis of a disease among underserved racial and ethnic populations; conducted in the USA; published in English in a peer-reviewed journal (years 2012-2022); study cohort composed of >50% non-white racial and ethnic populations.

DATA ANALYSIS

Primary outcomes were barriers to timely diagnosis of a disease. Screening and thematic abstraction were performed independently by two investigators, and data were synthesised using the 'Model of Pathways to Treatment' conceptual framework.

RESULTS

Sixteen studies from multiple clinical domains were included. Barriers to timely diagnosis emerged at the socioeconomic and sociocultural level (low health literacy, distrust in healthcare systems, healthcare avoidance, cultural and linguistic barriers), provider level (cognitive biases, breakdown in patient-provider communication, lack of disease knowledge) and health systems level (inequity in organisational health literacy, administrative barriers, fragmented care environment and a lack of organisational cultural competence). None of the existing studies explored diagnostic disparities among Asian Americans/Pacific Islanders, and few examined chronic conditions known to disproportionately affect historically underserved populations.

DISCUSSION

Historically underserved racial and ethnic patients encountered many challenges throughout their diagnostic journey. Systemic strategies are needed to address and prevent diagnostic disparities.

Disparities in burden of disease in patients with rheumatoid arthritis across racial and ethnic groups

To examine racial/ethnic differences in rheumatoid arthritis (RA) disease burden and change in clinical outcomes over time. We included CorEvitas Rheumatoid Arthritis Registry patients from two time periods (2013-2015 and 2018-2020). Clinical Disease Activity Index (CDAI) (as a continuous measure and as a dichotomous measure) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) were assessed at each visit. Marginal means and their corresponding 95% confidence interval (CI) by race/ethnicity were estimated for each outcome using adjusted mixed effects linear and logistic regression models. Overall and pairwise tests were conducted to detect differences between race/ethnicity groups. Of 9,363 eligible patients (8,142 White, 527 Black, 545 Hispanic, 149 Asian), most (76%-85%) were female. At Visit 1, the mean disease duration ranged from 9.8-11.8 years. Estimated CDAI was significantly higher for Hispanics compared to Whites at Visit 1 (11.1 vs. 9.9; pairwise P = 0.033) and Visit 2 (9.2 vs. 8.0, pairwise P = 0.005). Disease activity improved over the 5-year study period among all race/ethnicity groups, though Hispanics improved less than Whites. Disease activity improved over the 5-year period across all racial/ethnicity groups, and disparities between racial/ethnicity groups in disease activity and functional status did persist over time, suggesting that further effort is needed to understand the drivers of these discrepancies to close this race/ethnicity gap. Key Points • Disease activity improved over the 5-year period across all racial and ethnic groups. • Disparities between racial and ethnic groups in disease activity and functional status did persist over time, suggesting that further effort is needed to understand the drivers of these discrepancies and close this racial gap.

Evaluation of Antinuclear Antibody and Subserology Reflex Testing for the Diagnosis of Systemic Autoimmune Rheumatic Disorders in an Academic Teaching Hospital

OBJECTIVE

The aim of this study was to examine appropriate utilization of antinuclear antibody (ANA) screening tests with follow-up subserology tests (reflex testing) for diagnosing systemic autoimmune rheumatic disorder (SARD).

METHODS

We conducted a retrospective chart review of 3003 SARD-test orders at an academic teaching hospital from January to December 2019. Testing patterns were categorized as American College of Rheumatology (ACR)-recommended reflex testing, panel testing, or single subserology testing. We described testing patterns, assessed their diagnostic accuracy, and explored factors associated with reflex testing.

RESULTS

Reflex testing accounted for 79.7% of SARD test-ordering, whereas improper testing (panel or single subserology) accounted for the other 20.3%. Reflex testing was associated with significantly more SARD diagnoses than improper testing (P = .004). Testing patterns were significantly associated with race/ethnicity (P = .008), with reflex testing being less frequent than improper testing in Hispanics and Whites.

CONCLUSION

In summary, one-fifth (20.3%) of testing patterns for suspected SARD did not follow the ACR-recommended guidelines for using reflex testing. Use of reflex testing was associated with an increased frequency of SARD diagnosis.

Impact of Race, Gender, and Socioeconomic Status on Symptom Severity at Time of Urologic Referral

BACKGROUND AND OBJECTIVES

The Dysfunctional Voiding and Incontinence Scoring System (DVISS) is a validated tool to evaluate lower urinary tract dysfunction (LUTD) severity in children. DVISS provides a quantitative score (0-35) including a quality-of-life measure, with higher values indicating more/worse symptoms. Clinically, variability exists in symptom severity when patients present to pediatric urology with LUTD. We hypothesized that symptom severity at consultation varied based on race, gender, and/or socioeconomic status.

METHODS

All urology encounters at a single institution with completed modified DVISS scores 6/2015-3/2018 were reviewed. Initial visits for patients 5-21 years old with non-neurogenic LUTD were included. Patients with neurologic disorders or genitourinary tract anomalies were excluded. Wilcoxon rank sum tests compared scores between White and Black patients and between male and female patients. Multiple regression models examined relationships among race, gender, estimated median household income, and insurance payor type. All statistics were performed using Stata 15.

RESULTS

In total, 4086 initial patient visits for non-neurogenic LUTD were identified. Median DVISS scores were higher in Black (10) versus White (8) patients (p < 0.001). Symptom severity was higher in females (9) versus males (8) (p < 0.001). When estimated median income and insurance payer types were introduced into a multiple regression model, race, gender, and insurance payer type were significantly associated with symptom severity at presentation.

CONCLUSIONS

Race, gender, and socioeconomic status significantly impact LUTS severity at the time of urologic consultation. Future studies are needed to clarify the etiologies of these disparities and to determine their clinical significance.

Racial and Ethnic Differences in a Biochemical Marker of Rheumatoid Arthritis Disease Activity

OBJECTIVE

Racial and ethnic disparities in rheumatoid arthritis (RA) disease activity measures have been documented. We compared racial and ethnic differences in disease activity using multiple composite measures, including an objective measure, the multi-biochemical disease activity (MBDA) score.

METHODS

Data are derived from the University of California, San Francisco RA Cohort, a longitudinal observational cohort. Participants with at least one MBDA measure and self-reported race and ethnicity were included. Multivariable linear regression evaluated the association between race and ethnicity groups and mean MBDA score, adjusting for potential confounders, including symptom duration and medication use. Sensitivity analyses substituted the Clinical Disease Activity Index (CDAI) and the Disease Activity Score-28 joints with erythrocyte sedimentation rate (DAS28-ESR) for the MBDA in multivariable models.

RESULTS

We included 267 participants (86% female, mean age 52.7 ± 13.3 years). The majority were Latinx (n = 137; 51%), followed by Asian (n = 91; 34%). After adjustment, Latinx participants had the highest mean MBDA score (40.6 ± 2.1) compared with White participants at (32.8 ± 6.7). Black participants had the second highest mean MBDA score, followed by Asian participants (36.3 ± 5.3, 36.0 ± 2.7, respectively), although neither were significantly different from White participants. The trends observed for the CDAI and DAS28-ESR were similar to those for the MBDA.

CONCLUSION

We found significantly higher disease activity measured by the MBDA and DAS28-ESR in Latinx participants compared with White participants. We also found significantly higher disease activity in Asian participants compared with White participants with the DAS28-ESR. Our findings, although limited by the small number of White participants in the referent group, suggest that RA disease activity measures may be influenced by external factors that have differential impacts by racial and ethnic group.

Hispanic/Latino Perspectives on Hearing Loss and Hearing Healthcare: Focus Group Results

OBJECTIVES

To better understand the hearing health learning needs of Hispanic/Latino adults by assessing hearing healthcare (HHC) knowledge, attitudes, and behaviors to inform the development of a culturally and linguistically appropriate self-management program. Through a series of focus groups with members of the target audience, this study explored knowledge about hearing loss and interventions, cultural facilitators and barriers to HHC utilization, and preferences for hearing health education and information delivery. Opinions were also received on patient education materials designed to increase self-efficacy for managing hearing loss in daily life.

DESIGN

This work was guided by a practical framework of culturally competent interventions for addressing disparities in health and healthcare, centered on structural, clinical, and organizational barriers to care. A hybrid individualistic social psychology and social constructionist approach was used to build programmatic theory related to the primary research objective. Focus group goals were to generate a combination of personal opinions and collective experiences from participants with an a priori plan to analyze data using combined content analysis/grounded theory methods. Purposive sampling was used to select 31 participants who were Spanish-speaking, identified as Hispanic/Latino, and who had normal hearing or self-reported hearing difficulties. Thirteen focus groups were conducted using Microsoft Teams, and each group was audio and video recorded for later off-line transcription, translation, and analysis. A constant comparison approach was used to systematically organize focus group data into a structured format for interpretation. Transcripts were coded independently by two investigators, and emergent themes were derived and interpreted from the coded data.

RESULTS

Major and minor themes tied to the framework for culturally competent interventions included those related to sociocultural barriers to care. Structural barriers, including inconsistent access to quality care, lack of culturally and linguistically appropriate patient education materials, appointment wait times and intake processes, and referrals to specialty care, were most frequently experienced by participants. Clinical barriers most frequently cited were a lack of culturally and linguistically congruent healthcare providers and lack of language access during healthcare visits. Other major themes included hearing loss lived experiences, family and familism, and hearing-related patient education needs and preferences.

CONCLUSIONS

Focus group results were integrated into a Spanish-language hearing loss self-management program that is currently being evaluated in a randomized controlled trial. The themes uncovered provided insight regarding the knowledge, attitudes, and beliefs about hearing loss and HHC, including hearing-related learning needs, of Hispanic/Latino adults in this sample.

“The medications are the decision-makers…” Making reproductive and medication use decisions among female patients with rheumatoid arthritis: a constructivist grounded theory

Objective

To examine how female patients with RA form decisions about having children, pregnancy, and medication use.

Methods

We employed a constructivist grounded theory design and recruited female participants who are 18 years or older, have a rheumatologist-confirmed RA diagnosis, live in Canada, and are able to communicate in English or French. We collected data through semi-structured individual and focus group interviews using telephone or video conferencing technology. Data collection and analysis were iterative, employed theoretical sampling, reflexive journaling, and peer debriefing, and culminated in a theoretical model.

Results

We recruited 21 participants with a mean age of 34 years and median 10 years since RA diagnosis. Overall, 33% had never been pregnant, 57% had previously been pregnant, and 10% were pregnant at the time of interview. Of those who had experienced pregnancy, 64% had at least one pregnancy while diagnosed with RA and of those, 56% used DMARD(s) during a pregnancy. We constructed a patient-centred framework depicting the dynamic relationships between 4 decision-making processes—(1) using medications, (2) having children, (3) planning pregnancy, and (4) parenting—and the substantial impact of healthcare providers on patients’ experiences making these decisions. These processes were further influenced by participants’ intersecting identities and contextual factors, particularly attitudes towards health and medications, disease onset and severity, familial support system, and experiences interacting with the healthcare system.

Conclusion

Our framework provides insight into how patients make reproductive decisions in the context of managing RA and the opportunities for providers to support them at each decision-making process. A patient-centred care approach is suggested to support female patients with RA in making reproductive and medication choices aligning with their individual desires, needs, and values.

Rheumatoid Arthritis and Associated-Interstitial Lung Disease: Mortality Rates and Trends

RATIONALE

The burden of rheumatoid arthritis (RA) and RA-associated interstitial lung disease (RA-ILD) in recent years has not been well characterized.

OBJECTIVE

In this study, we sought to describe RA and RA-ILD-related mortality rates and trends in the U.S. from 2005-2018, stratified by demographics.

METHODS

We used the Multiple Cause of Death Database available through the Centers for Disease Control and prevention website which contains data of all deceased U.S. residents. RA and RA-ILD-related deaths were identified using ICD-10 codes. We examined the age-adjusted mortality rates and trends stratified by demographics.

RESULTS

RA and RA-ILD-related mortality rates were higher in females and older age groups. However, the prevalence of ILD was higher in male decedents with RA compared to female decedents with RA (13.3% vs. 8.7%). RA-related mortality rates were the highest in Native Americans followed by Whites. Compared to Whites, Hispanics had lower RA-related mortality rates but higher RA-ILD-related mortality rates. Overall RA-related mortality rates per 1,000,000 population decreased from 30.6 in 2005 to 22.2 in 2018. RA-related mortality rates declined in both sex, all races, and all age groups. However, RA-ILD-related mortality rates remained stable in both sex, all races, and all age groups except for ages 65 to 84 years, in which the rates declined.

CONCLUSIONS

The overall RA-related mortality rates are decreasing, however, RA-ILD-related mortality rates remain stable except in age groups 65-84 years. This would suggest that therapies for RA and improvement in the management of other comorbidities have improved the overall outcomes in RA patients, but have had limited effect in the subgroup of patients with RA-ILD.

Medical Spanish Musculoskeletal and Dermatologic Educational Module

INTRODUCTION

While many medical schools provide opportunities in medical Spanish for medical students, schools often struggle with identifying a structured curriculum. The purpose of this module was to provide a flexible, organ system-based approach to teaching and learning musculoskeletal and dermatologic Spanish terminology, patient-centered communication skills, and sociocultural health contexts.

METHODS

An 8-hour educational module for medical students was created to teach musculoskeletal and dermatologic medical communication skills in Spanish within the Hispanic/Latinx cultural context. Participants included 47 fourth-year medical students at an urban medical school with a starting minimum Spanish proficiency at the intermediate level. Faculty provided individualized feedback on speaking, listening, and writing performance of medical Spanish skills, and learners completed a written pre- and postassessment testing skills pertaining to communication domains of vocabulary, grammar, and comprehension as well as self-reported confidence levels.

RESULTS

Students demonstrated improvement in vocabulary, grammar, comprehension, and self-confidence of musculoskeletal and dermatologic medical Spanish topics. While students with overall lower starting proficiency levels (intermediate) scored lower on the premodule assessment compared to higher proficiency students (advanced/native), the postmodule assessment did not show significant differences in skills performance among these groups.

DISCUSSION

An intermediate Spanish level prerequisite for this musculoskeletal and dermatologic module can result in skills improvement for all learners despite starting proficiency variability. Future study should evaluate learner clinical performance and integration of this module into other educational settings such as graduate medical education (e.g., orthopedic, rehabilitation, and dermatology residency programs) and other health professions (e.g., physical therapy and nursing).