Regional and temporal variation in the treatment of rheumatoid arthritis across the UK: a descriptive register-based cohort study

Abstract

Objectives: To describe current disease-modifying antirheumatic drugs (DMARDs) prescription in rheumatoid arthritis (RA) with reference to best practice and to identify temporal and regional trends in the UK.

Design: Descriptive, register-based cohort study.

Participants: Permanently registered patients aged ≥18 years with a recorded diagnosis of RA between 1 January 1995 and 31 March 2010 and matched controls. Participants with RA were identified through screening of all patients in the General Practice Research Database (GPRD) with a clinical or referral record for RA and at least 1 day of follow-up.

Setting: 639 general practices in the UK supplying data to the GPRD.

Main outcome measures: Medication prescribing between 3 and 12 months of RA diagnosis by region and time period (1995-1999, 2000-2005 and 2006-April 2010).

Results: Of the 35 911 patients in the full RA cohort, 15 259 patients (42%) had incident RA. Analysis of prescribing in incident RA patients demonstrated that between 1995 (baseline) and 2010 there was a substantial increase in DMARD, and specifically methotrexate, prescribing across all regions with a less marked increase in combination DMARD prescribing. Taking 12-month prescribing as a snapshot: DMARD prescribing was 19-49% at baseline increasing to 45-74% by 2006-April 2010; methotrexate prescribing was 4-16% at baseline increasing to 32-60%; combination DMARD prescribing was 0-8% at baseline increasing to 3-17%. However, there was marked regional variation in the proportion of RA patients receiving DMARD regardless of time period.

Conclusions: There has been a substantial increase in prescribing of DMARDs for RA since 1995; however, regional variation persists across the UK with relative undertreatment, according to established best practice. Improved implementation of evidence-based best clinical practice to facilitate removal of treatment variation is warranted. This may occur as a result of the implementation of published national guidance.

Figure 1

(A) Percentage of patients prescribed disease-modifying antirheumatic drugs (DMARDs) at 12 months by region for the time period 1995–1999. (B) Percentage of patients prescribed DMARDs at 12 months by region for the time period 2000–2005. (C) Percentage of patients prescribed DMARDs at 12 months by region for the time period 2006–2010.