Understanding disease modifying antirheumatic drug use in older adults with late-onset rheumatoid arthritis

PROJECT SUMMARY/ABSTRACT Rheumatoid arthritis (RA) is a chronic, debilitating inflammatory disease that affects 1.3 million older adults in the US. The number of older adults living with RA is growing and one-third are diagnosed with late-onset RA (LORA), characterized by more severe disease, greater comorbidity burden at time of diagnosis, and disability. Older adults with RA are less likely to receive effective disease modifying antirheumatic drugs (DMARDs) and more likely to receive long-term glucocorticoids alone for treatment which suggest we may be accepting less than optimal management in this population and better outcomes may be achievable. Dr. Jiha Lee is an Assistant Professor at the University of Michigan whose long-term goal is to become an independent investigator and national leader in geriatric rheumatology focused on advancing the science of effective medication use to improve the care of older adults with rheumatic diseases. This K23 Mentored Patient- Oriented Research Career Development Award application (PA-20-205) will support Dr. Lee to gain additional training and mentoring, and by completing the proposed work to become one of the few clinician-scientists with unique qualifications at the intersection of rheumatology, aging, pharmacoepidemiology, and mixed methods research to conduct rigorous aging research in the field of rheumatology. The overarching scientific goal of this mentored-research proposal is to investigate suboptimal DMARD use and tolerability to different treatment regimens in usual care among older adults with LORA and to engage patients and providers to better understand observed outcomes. The proposed explanatory sequential mixed methods study will use nationally representative Medicare claims data for Aims 1 and 2, followed by in-depth semi-structured interviews with patients and providers for Aim 3. Specifically, in Aim 1, Dr. Lee will examine patient and provider/healthcare factors associated with suboptimal DMARD use in older adults with LORA during the first 12 months after index date of diagnosis, gathering critical information to identify targets for future efforts to improve DMARD use. To build toward more evidence-based prescribing, in Aim 2 she will examine outcomes associated with different treatment regimens and identify patients at greatest risk of poor outcomes. In Aim 3, she will use the results from Aims 1 and 2 to guide the sampling strategy and discussion guide development to engage patients with LORA and providers to examine and inform additional potentially important factors that drive treatment approaches. Dr. Lee will conduct all work at the rich environment of the University of Michigan, with guidance from her exceptional team of mentors and advisors led by Dr. Julie Bynum. The proposed work will lay the foundation to identify subpopulations at risk of poor outcomes and build the evidence base for an R01-level application to inform development and evaluation of age-appropriate approaches to treatment of LORA.