Urban and Rural Patterns of Health Care Utilization Among People With Rheumatoid Arthritis and Osteoarthritis in a Large US Patient Registry.

OBJECTIVE: Rural residence has been associated with health disparities in rheumatic diseases and other chronic conditions in the United States. This study aimed to determine if a relationship exists between geographic residence and health care utilization outcomes for people with rheumatoid arthritis (RA) and osteoarthritis (OA) in a US-wide rheumatic disease registry. METHODS: Participants were in FORWARD, The National Databank for Rheumatic Diseases, a US-wide rheumatic disease longitudinal cohort completing questionnaires between 1999 and 2019. Health care utilization variables (ie, medical visits and diagnostic tests) from six-month questionnaires were analyzed by geographic categories (small rural/isolated, large rural, and urban). Double selection LASSO with Poisson regression was used to assess the best model when examining the association between health care utilization variables and geographic residence. RESULTS: Among 37,802 participants with RA, urban residents were more likely than small rural residents to use in-person health care by most measures including physician visits and diagnostic tests. Urban residents reported more rheumatologist visits (incidence rate ratio [IRR], 1.22; 95% confidence interval [95% CI], 1.18-1.27) but fewer primary care visits (IRR 0.90; 95% CI 0.85-0.94). Among 8,248 participants with OA, urban residents were also more likely than rural residents to report health care utilization by most measures. CONCLUSION: Individuals residing in urban areas were more likely than those in rural areas to report in-person health care utilization. Specifically, urban residents with RA were more likely to report rheumatologist visits, but less likely to report primary care visits. Less disparity existed in OA health care utilization, although an urban-rural disparity still existed by most measures.

Recalcitrant Herpes Zoster Ophthalmicus in a Patient Discovered to Have Underlying Functional Natural Killer Cell Deficiency.

PURPOSE: To report the management of a patient with chronic herpes zoster ophthalmicus with previously undiagnosed natural killer cell deficiency. METHODS: A 50-year-old female presented with herpes zoster ophthalmicus that despite appropriate treatment progressed to uveitis and expansion of the lesions. Multiple attempts to wean the patient off therapeutic anti-viral medications continued to result in reoccurrence of the disease. Discovery of underlying natural killer cell deficiency prompted indefinite treatment with therapeutic anti-viral medication. RESULTS: After multiple flares of herpes zoster ophthalmicus over 3 years, seven prior to the discovery of the immunodeficiency, she developed unilateral corneal scarring on the affected side. At this time, her visual acuity was measured to be uncorrected at 20/150 with improvement to 20/25-1 with refraction. CONCLUSIONS: This case highlights the need for further immunological investigation and unconventional medical management with recurrent viral infections to prevent visual morbidity.

Posttraumatic Stress Disorder, Depression, Anxiety, and Persistence of Methotrexate and TNF Inhibitors in Patients with Rheumatoid Arthritis.

OBJECTIVE: To examine the relationship of posttraumatic stress disorder (PTSD) with earlier treatment discontinuation and medication adherence in US veterans with rheumatoid arthritis (RA). METHODS: Veterans Affairs (VA) administrative data (2005-2014) were used to define unique dispensing episodes of methotrexate (MTX) and tumor necrosis factor inhibitors (TNFi) for veterans with RA. Diagnosis codes were used to categorize patients into mutually exclusive groups: PTSD (with/without depression/anxiety), depression/anxiety without PTSD, and neither psychiatric diagnosis. Multivariable Cox proportional hazards models were used to evaluate associations between psychiatric diagnoses and time to disease-modifying antirheumatic drug discontinuation (lapse in refill >90 days). Multivariable logistic regression was used to examine associations of diagnoses with medication nonadherence (proportion of days covered <0.8). RESULTS: There were 15 081 dispensing episodes of MTX and 8412 dispensing episodes of TNFi. PTSD was independently associated with a greater likelihood of earlier discontinuation of both MTX (hazard ratio [HR] 1.15 [1.10-1.21]) and TNFi (HR 1.20 [1.13-1.28]). Depression/anxiety had a comparable risk of discontinuation for both MTX (HR 1.14 [1.10-1.19]) and TNFi (HR 1.16 [1.10-1.22]). Depression/anxiety, but not PTSD, was associated with higher odds of MTX (odds ratio [OR] 1.12 [1.03-1.22]) and TNFi (OR 1.14 [1.02-1.27]) nonadherence. CONCLUSION: Veterans with RA and comorbid PTSD, depression, or anxiety had poor persistence of MTX and TNFi therapies. These results suggest that earlier discontinuation and low adherence to therapy among patients with RA with these psychiatric comorbidities may contribute to worse disease outcomes. Mechanisms by which these comorbidities contribute to lower adherence deserve further investigation and may lead to targeted interventions to improve disease outcomes.