Do Rheumatologists See Past RA Patients’ Race?

When 159 rheumatologists were given a series of hypothetical patient cases that differed only in the patients’ race or ethnicity, their recommendations for or against biologic agents for rheumatoid arthritis (RA) therapy were largely the same, results of a randomized survey study indicated.

Three of the four cases were designed to reflect “some level of treatment decision ambiguity,” explained Julia F. Simard, ScD, SM, of Stanford University in California, and colleagues writing in ACR Open Rheumatology. In these cases, “there was little to no variability” in the rates of proposed biologics prescribing, the group reported.

The fourth case was meant to “strongly favor” biologic therapy, and here, too, the rates didn’t differ.

Simard and colleagues expressed surprise at the finding that race/ethnicity didn’t seem to affect treatment decisions. “This contrasts with our initial hypothesis, which was that non-white cases would be less likely to receive [biologics],” they wrote.

That the study was based on a written survey, and not real patients in an exam room, might have affected the outcomes, the authors admitted. “[G]iven the current awareness of the pernicious impact of structural racism on health outcomes, we cannot rule out social desirability bias” as influencing responses.

In addition, the investigators noted that they “did not specify insurance status in our case vignettes and therefore cannot determine how assumptions by participants about insurance may influence these results.” In most areas of the U.S., Black and Hispanic individuals are more likely to have public or no insurance, putting expensive biologic drugs out of reach for many.

Simard and colleagues also suggested that racist stereotypes could actually have favored biologic prescriptions for minority patients. “Triple therapy [with conventional anti-rheumatic drugs] can require up to seven or more pills per day, with laboratory surveillance every 3 months, whereas [biologic] injection or infusion occurs every 1 to 8 weeks, typically with laboratory surveillance every 6 months,” the authors explained. “Thus, perceptions regarding how patients of different races and ethnicities adhere to medications and interact with healthcare may also be at play.”

Consequently, the group stopped well short of concluding that rheumatology practice is unaffected by racism. Rather, they wrote, the study “adds to [the] conversation” about racial, ethnic, and sex disparities in rheumatology practice.

Study Details

Simard and colleagues conceived the study in response to mixed findings from previous research. Disparities have certainly been found before, but Simard’s group said those studies came with too many limitations to permit solid conclusions. A complicating factor is that decisions to initiate biologics are indeed complicated, depending not only on clinical factors but also patients’ socioeconomic position, and their providers’ attitudes.

The four vignettes provided to rheumatologists described a patient’s age, sex, clinical history, and exam findings. Each vignette came in three versions, differing only by the patient’s race/ethnicity: white, Black, or Hispanic. These vignettes concluded with a question about the recommended next step for therapy.

Respondents received randomly selected versions of each vignette. Just under 2,000 were distributed to valid email addresses; thus the response rate was about 8%.

As noted earlier, three of the vignettes were intended to elicit answers that could include either adjusting conventional drugs or starting a biologic agent, though slightly favoring the latter (as suggested by current guidelines). The fourth was more clear-cut in favor of biologics.

Regarding the respondents, they were evenly split between men and women and mean age was 54, while 65% were white and 29% were Asian. Half had been in practice more than 20 years; 13% had been practicing less than 5 years. Just under half worked in academic institutions and one-third were in private practice.

Each vignette had between 50 and 60 responses. Given these rather small numbers, no statistically significant differences were seen in proposed biologics prescribing according to the patients’ race/ethnicity. Numerical differences were small enough that a change in one or two rheumatologists’ answers would largely erase them. That was another notable limitation to the study.

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