Patient preferences play role in racial disparities in rheumatoid arthritis treatment

New study examined whether African-American and white patients with RA differ in how they make trade-offs between risks and benefits related to treatment

Racial disparities in the delivery of healthcare occur even among insured populations with access to care. This suggests that some of the differences in health care utilization among different racial groups may be due to patient preferences. Rheumatoid arthritis (RA) treatment decisions are frequently complex, requiring multiple trade-offs between symptom relief, long-term reduction of disability, adverse events and serious complications. A new study examined whether African American and white patients with RA differ in how they make trade-offs between risks and benefits related to treatment. The study was published in the April issue of Arthritis Care & Research (www3.interscience.wiley.com/journal/77005015/).

Led by Dr. Liana Fraenkel of Yale University, researchers examined how 136 RA patients made trade-offs about specific treatment characteristics related to commonly used RA drugs. These included benefits such as the chance of remission or symptom improvement, and risks such as side effects and theoretical risk of cancer. They analyzed how patients made trade-offs in treatment decisions to determine how respondents value specific characteristics.

The results showed that there were significant differences in the ways that African American and white patients evaluated treatment characteristics. African American patients, who comprised 49 percent of the study sample, attached greater importance to the risk of toxicity, particularly for rare, serious adverse events, and less importance to the likelihood of benefit than white patients. For example, African Americans assigned the greatest importance to the theoretical risk of cancer, whereas white patients were most concerned with the likelihood of remission and halting radiographic progression.

Until now, it has been widely believed that differences in treatment by race can be corrected by changes in either health care providers or the health care system. This is because research on health care disparities has largely focused on access to care, lack of insurance, quality of care due to unconscious practitioner bias and social factors.

Although the Institute of Medicine's model of health disparities includes an acknowledgement that these may be due in part to differences in preferences of care, few studies have tested this notion and racial/cultural differences in risk/benefit perception remain an under-researched field.

"Our study is important because, to the best of our knowledge, this is the first study to formally assess whether risk preference for therapy is one of the potential explanations of the lower use among African Americans of more effective, although more risky, therapy for a chronic disabling disease," the authors state. They point out that disparate models of health and illness may lead to disparate patient preferences, as well as limited communication during clinical visits.

The study showed that African Americans were significantly more risk averse than their white counterparts, which the authors theorize may be due to "cultural risk aversion for gains." This type of risk aversion is based on a learned distrust or low expectations of the healthcare system that arise when a subgroup observes significant gains in lifespan, economic prosperity and power of the larger culture, but does not experience these gains even though they live in the same country or culture.

The authors conclude: "Given these results, physicians should confirm that patients have accurate expectations regarding the natural history and treatment of their disease, and ensure that patient preferences are based on an informed assessment of the pros and cons related to available treatment options." ###

Article: "Understanding Why Rheumatoid Arthritis Patient Treatment Preferences Differ By Race," Florina Constantinescu, Suzanne Goucher, Arthur Weinstein, Wally Smith, Liana Fraenkel, Arthritis & Rheumatism (Arthritis Care & Research), April 2009.

Contact: Sean Wagner medicalnews@bos.blackwellpublishing.com 781-388-8550 Wiley-Blackwell

Image: Rheumatoid Arthritis