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Racial and Ethnic Disparities in Rheumatoid Arthritis

Current Rheumatology Reports volume 14, pages 463–471 (2012)Cite this article

Abstract

Racial and ethnic health disparities are a national health issue. They are well described in other chronic diseases, but in rheumatoid arthritis (RA), research into their causes, outcomes, and elimination is in its early stages. Health disparities occur in a complex milieu, with system-level, provider-level, and individual-level factors playing roles. Dissecting the overlapping aspects of race/ethnicity, socioeconomic variables, and how their individual components combine to explain the magnitude of disparities in RA can be challenging. Recent research has focused on the extent to which treatment preferences, adherence, trust in physicians, patient–physician communication, health literacy, and depression have contributed to observed disparities in RA. Practicing evidence-based medicine, improving patient–physician communication skills, reducing language and literacy barriers, improving adherence to therapies, raising awareness of racial/ethnic disparities, and recognizing comorbidities such as depression are steps clinicians may take to help eliminate racial/ethnic disparities in RA.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part I. Arthritis Rheum. 2008;58:15–25.

    PubMed  Article  Google Scholar 

  2. Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is the incidence of rheumatoid arthritis rising? results from Olmsted County, Minnesota, 1955–2007. Arthritis Rheum. 2010;62:1576–82.

    PubMed  Article  Google Scholar 

  3. Birnbaum H, Pike C, Kaufman R, Marynchenko M, Kidolezi Y, Cifaldi M. Societal cost of rheumatoid arthritis patients in the US. Curr Med Res Opin. 2010;26:77–90.

    PubMed  Article  Google Scholar 

  4. Simons WR, Rosenblatt LC, Trivedi DN. The economic consequences of rheumatoid arthritis: analysis of Medical Expenditure Panel Survey 2004, 2005, and 2006 data. J Occup Environ Med. 2012;54:48–55.

    PubMed  Article  Google Scholar 

  5. Jantti J, Aho K, Kaarela K, Kautiainen H. Work disability in an inception cohort of patients with seropositive rheumatoid arthritis: a 20 year study. Rheumatology (Oxford). 1999;38:1138–41.

    Article  CAS  Google Scholar 

  6. Sokka T, Kautiainen H, Mottonen T, Hannonen P. Work disability in rheumatoid arthritis 10 years after the diagnosis. J Rheumatol. 1999;26:1681–5.

    PubMed  CAS  Google Scholar 

  7. Barrett EM, Scott DG, Wiles NJ, Symmons DP. The impact of rheumatoid arthritis on employment status in the early years of disease: a UK community-based study. Rheumatology (Oxford). 2000;39:1403–9.

    Article  CAS  Google Scholar 

  8. Eberhardt K, Larsson BM, Nived K, Lindqvist E. Work disability in rheumatoid arthritis—development over 15 years and evaluation of predictive factors over time. J Rheumatol. 2007;34:481–7.

    PubMed  Google Scholar 

  9. Theis KA, Murphy L, Hootman JM, Helmick CG, Yelin E. Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18–64: 2002 National Health Interview Survey data. Arthritis Rheum. 2007;57:355–63.

    PubMed  Article  Google Scholar 

  10. 106th Congress. S. 1880—106th Congress: Minority Health and Health Disparities Research and Education Act of 2000. Available from: http://www.govtrack.us/congress/bills/106/s1880; April 16, 2012.

  11. Thomson GE, Mitchell F, Williams M, editors. Examining the Health Disparities Research Plan of the National Institutes of Health: unfinished business. Washington: The National Academies Press; 2006.

    Google Scholar 

  12. • Healthy People 2010 final review—complete review. Available from: http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf; April 16, 2012. This final review of the 2000–2010 decade of the Healthy People initiative reveals the national importance of health disparities in a wide range of conditions and provides data regarding ongoing inequalities in care, morbidity, and mortality in racial/ethnic minorities.

  13. Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington: The National Academies Press; 2002.

    Google Scholar 

  14. Bridges Jr SL, Hughes LB, Mikuls TR, et al. Early rheumatoid arthritis in African-Americans: the CLEAR Registry. Clin Exp Rheumatol. 2003;21 Suppl 31:S138–45.

    PubMed  Google Scholar 

  15. Zhang J, Redden DT, McGwin Jr G, et al. Generalized bone loss as a predictor of three-year radiographic damage in African American patients with recent-onset rheumatoid arthritis. Arthritis Rheum. 2010;62:2219–26.

    PubMed  Article  Google Scholar 

  16. Mikuls TR, Saag KG, Curtis J, et al. Prevalence of osteoporosis and osteopenia among African Americans with early rheumatoid arthritis: the impact of ethnic-specific normative data. J Natl Med Assoc. 2005;97:1155–60.

    PubMed  Google Scholar 

  17. Hughes LB, Morrison D, Kelley JM, et al. The HLA-DRB1 shared epitope is associated with susceptibility to rheumatoid arthritis in African Americans through European genetic admixture. Arthritis Rheum. 2008;58:349–58.

    PubMed  Article  Google Scholar 

  18. Hughes LB, Reynolds RJ, Brown EE, et al. Most common single-nucleotide polymorphisms associated with rheumatoid arthritis in persons of European ancestry confer risk of rheumatoid arthritis in African Americans. Arthritis Rheum. 2010;62:3547–53.

    PubMed  Article  Google Scholar 

  19. Burgos PI, Causey ZL, Tamhane A, et al. Association of IL4R single-nucleotide polymorphisms with rheumatoid nodules in African Americans with rheumatoid arthritis. Arthritis Res Ther. 2010;12:R75.

    PubMed  Article  Google Scholar 

  20. Bridges Jr SL, Causey ZL, Burgos PI, et al. Radiographic severity of rheumatoid arthritis in African Americans: results from a multicenter observational study. Arthritis Care Res (Hoboken). 2010;62:624–31.

    Article  Google Scholar 

  21. Mikuls TR, Levan T, Gould KA, et al. Impact of interactions of cigarette smoking with NAT2 polymorphisms on rheumatoid arthritis risk in African Americans. Arthritis Rheum. 2012;64:655–64.

    PubMed  Article  CAS  Google Scholar 

  22. House JS. Understanding social factors and inequalities in health: 20th century progress and 21st century prospects. J Health Soc Behav. 2002;43:125–42.

    PubMed  Article  Google Scholar 

  23. •• Schmajuk G, Trivedi AN, Solomon DH, et al. Receipt of disease-modifying antirheumatic drugs among patients with rheumatoid arthritis in Medicare managed care plans. JAMA. 2011;305:480–6. This national report of the Medicare HEDIS RA measure revealed lower rates of DMARD receipt in RA Medicare patients who were male, nonwhite, and of low socioeconomic status.

    PubMed  Article  CAS  Google Scholar 

  24. Bruce B, Fries JF, Murtagh KN. Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study. J Rheumatol. 2007;34:1475–9.

    PubMed  Google Scholar 

  25. Suarez-Almazor ME, Berrios-Rivera JP, Cox V, Janssen NM, Marcus DM, Sessoms S. Initiation of disease-modifying antirheumatic drug therapy in minority and disadvantaged patients with rheumatoid arthritis. J Rheumatol. 2007;34:2400–7.

    PubMed  Google Scholar 

  26. Kyburz D, Gabay C, Michel BA, Finckh A. The long-term impact of early treatment of rheumatoid arthritis on radiographic progression: a population-based cohort study. Rheumatology (Oxford). 2011;50:1106–10.

    Article  Google Scholar 

  27. Nell VP, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (Oxford). 2004;43:906–14.

    Article  CAS  Google Scholar 

  28. Lard LR, Visser H, Speyer I, et al. Early versus delayed treatment in patients with recent-onset rheumatoid arthritis: comparison of two cohorts who received different treatment strategies. Am J Med. 2001;111:446–51.

    PubMed  Article  CAS  Google Scholar 

  29. Finckh A, Bansback N, Marra CA, et al. Treatment of very early rheumatoid arthritis with symptomatic therapy, disease-modifying antirheumatic drugs, or biologic agents: a cost-effectiveness analysis. Ann Intern Med. 2009;151:612–21.

    PubMed  Google Scholar 

  30. •• Barton JL, Trupin L, Schillinger D, et al. Racial and ethnic disparities in disease activity and function among persons with rheumatoid arthritis from university-affiliated clinics. Arthritis Care Res (Hoboken). 2011;63:1238–46. This article highlights the concept that disparities in care are influenced by both race/ethnicity and clinical care location (university vs. public clinic). At the university clinic, white patients had decreased disease activity and disability and were more likely to be prescribed a biologic agent than were nonwhite, non-English-speaking, and/or immigrant patients. Patients at the public clinic overall had higher disease activity, but the racial/ethnic disparities between groups were not apparent.

    Article  CAS  Google Scholar 

  31. Bruce B, Fries JF. Rheumatologist perceptions of sources of health care disparities in minority rheumatoid arthritis patients. J Clin Rheumatol. 2009;15:145–7.

    PubMed  Article  Google Scholar 

  32. Harrison MJ, Farragher TM, Clarke AM, Manning SC, Bunn DK, Symmons DP. Association of functional outcome with both personal- and area-level socioeconomic inequalities in patients with inflammatory polyarthritis. Arthritis Rheum. 2009;61:1297–304.

    PubMed  Article  Google Scholar 

  33. Callahan LF, Cleveland RJ, Li X, et al. Current social position associated with rheumatoid arthritis severity and self-reported health outcomes in African Americans. Arthritis Rheum. 2011;63 Suppl 10:1545.

    Google Scholar 

  34. Cleveland RJ, Schwartz TA, Jonas BL, et al. Influence of lifecourse social position on rheumatoid arthritis disease severity in African Americans. Arthritis Rheum. 2011;63 Suppl 10:2642.

    Google Scholar 

  35. Carter C, Changolkar A, Scott McKenzie R. Adalimumab, etanercept, and infliximab utilization patterns and drug costs among rheumatoid arthritis patients. J Med Econ. 2011.

  36. Wolfe F, Michaud K. Out-of-pocket expenses and their burden in patients with rheumatoid arthritis. Arthritis Rheum. 2009;61:1563–70.

    PubMed  Article  Google Scholar 

  37. Karaca-Mandic P, Joyce GF, Goldman DP, Laouri M. Cost sharing, family health care burden, and the use of specialty drugs for rheumatoid arthritis. Health Serv Res. 2010;45:1227–50.

    PubMed  Article  Google Scholar 

  38. Beard AJ, Sleath B, Blalock SJ, et al. Predictors of rheumatoid arthritis patient-physician communication about medication costs during visits to rheumatologists. Arthritis Care Res (Hoboken). 2010;62:632–9.

    Article  Google Scholar 

  39. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient–physician relationship. JAMA. 1999;282:583–9.

    PubMed  Article  CAS  Google Scholar 

  40. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94:2084–90.

    PubMed  Article  Google Scholar 

  41. • Constantinescu F, Goucher S, Weinstein A, Fraenkel L. Racial disparities in treatment preferences for rheumatoid arthritis. Med Care. 2009;47:350–5. This article explores the relationship of race to treatment preferences in RA. Fewer African-American patients preferred aggressive therapy, as compared with white patients with the same disease activity.

    PubMed  Article  Google Scholar 

  42. •• Constantinescu F, Goucher S, Weinstein A, Smith W, Fraenkel L. Understanding why rheumatoid arthritis patient treatment preferences differ by race. Arthritis Rheum. 2009;61:413–8. The authors explored racial differences in treatment preferences by studying the decision making behind the trade-offs patients made between the theoretical risks/benefits of RA therapies. They determined that a greater proportion of white patients were concerned with likelihood of benefit, while a greater proportion of African-Americans were concerned with the risks of toxicity.

    PubMed  Article  Google Scholar 

  43. Salt E, Frazier SK. Adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a narrative review of the literature. Orthop Nurs. 2010;29:260–75.

    PubMed  Article  Google Scholar 

  44. Garcia-Gonzalez A, Richardson M, Garcia Popa-Lisseanu M, et al. Treatment adherence in patients with rheumatoid arthritis and systemic lupus erythematosus. Clin Rheumatol. 2008;27:883–9.

    PubMed  Article  Google Scholar 

  45. Garcia Popa-Lisseanu MG, Greisinger A, Richardson M, et al. Determinants of treatment adherence in ethnically diverse, economically disadvantaged patients with rheumatic disease. J Rheumatol. 2005;32:913–9.

    PubMed  Google Scholar 

  46. • Cannon GW, Mikuls TR, Hayden CL, et al. Merging Veterans Affairs rheumatoid arthritis registry and pharmacy data to assess methotrexate adherence and disease activity in clinical practice. Arthritis Care Res (Hoboken). 2011;63:1680–90. This Veterans Affairs study linked the lower doses of methotrexate actually taken by those with low medication adherence (vs. high medication adherence) with increased disease activity. African-American patients were more likely to be in the low-adherence group.

    Article  Google Scholar 

  47. van den Bemt BJ, den Broeder AA, van den Hoogen FH, et al. Making the rheumatologist aware of patients' non-adherence does not improve medication adherence in patients with rheumatoid arthritis. Scand J Rheumatol. 2011;40:192–6.

    PubMed  Article  Google Scholar 

  48. Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expect. 2004;7:235–45.

    PubMed  Article  Google Scholar 

  49. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79:613–39.

    PubMed  Article  CAS  Google Scholar 

  50. Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract. 1997;44:169–76.

    PubMed  CAS  Google Scholar 

  51. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Serv Res. 2002;37:1419–39.

    PubMed  Article  Google Scholar 

  52. Thom DH, Kravitz RL, Bell RA, Krupat E, Azari R. Patient trust in the physician: relationship to patient requests. Fam Pract. 2002;19:476–83.

    PubMed  Article  Google Scholar 

  53. O'Malley AS, Sheppard VB, Schwartz M, Mandelblatt J. The role of trust in use of preventive services among low-income African-American women. Prev Med. 2004;38:777–85.

    PubMed  Article  Google Scholar 

  54. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.

    PubMed  CAS  Google Scholar 

  55. Parchman ML, Burge SK. The patient–physician relationship, primary care attributes, and preventive services. Fam Med. 2004;36:22–7.

    PubMed  Google Scholar 

  56. Schneider J, Kaplan SH, Greenfield S, Li W, Wilson IB. Better physician–patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med. 2004;19:1096–103.

    PubMed  Article  Google Scholar 

  57. Keating NL, Gandhi TK, Orav EJ, Bates DW, Ayanian JZ. Patient characteristics and experiences associated with trust in specialist physicians. Arch Intern Med. 2004;164:1015–20.

    PubMed  Article  Google Scholar 

  58. Berrios-Rivera JP, Street Jr RL, Garcia Popa-Lisseanu MG, et al. Trust in physicians and elements of the medical interaction in patients with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Rheum. 2006;55:385–93.

    PubMed  Article  Google Scholar 

  59. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–39.

    PubMed  Article  Google Scholar 

  60. Swearingen CJ, McCollum L, Daltroy LH, Pincus T, Dewalt DA, Davis TC. Screening for low literacy in a rheumatology setting: more than 10 % of patients cannot read "cartilage," "diagnosis," "rheumatologist," or "symptom". J Clin Rheumatol. 2010;16:359–64.

    PubMed  Google Scholar 

  61. Hirsh JM, Gardner EM. A pilot study to determine whether patients are likely to understand the educational information available on-line about arthritic disorders. J Clin Rheumatol. 2009;15:367–8.

    PubMed  Article  Google Scholar 

  62. •• Hirsh JM, Boyle DJ, Collier DH, et al. Limited health literacy is a common finding in a public health hospital's rheumatology clinic and is predictive of disease severity. J Clin Rheumatol. 2011;17:236–41. In this article, the authors found elevated levels of limited health literacy in racial/ethnic minorities versus whites at a public health hospital’s rheumatology clinic. Limited health literacy in this population was independently correlated with functional disability.

    PubMed  Google Scholar 

  63. Rudd RE, Blanch DC, Gall V, et al. A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management. Patient Educ Couns. 2009;75:334–9.

    PubMed  Article  Google Scholar 

  64. Dickens C, McGowan L, Clark-Carter D, Creed F. Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis. Psychosom Med. 2002;64:52–60.

    PubMed  Google Scholar 

  65. Katz PP, Yelin EH. Prevalence and correlates of depressive symptoms among persons with rheumatoid arthritis. J Rheumatol. 1993;20:790–6.

    PubMed  CAS  Google Scholar 

  66. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101–7.

    PubMed  Article  CAS  Google Scholar 

  67. Treharne GJ, Lyons AC, Kitas GD. Suicidal ideation in patients with rheumatoid arthritis: research may help identify patients at high risk. BMJ. 2000;321:1290.

    PubMed  Article  CAS  Google Scholar 

  68. Fuller-Thomson E, Shaked Y. Factors associated with depression and suicidal ideation among individuals with arthritis or rheumatism: findings from a representative community survey. Arthritis Rheum. 2009;61:944–50.

    PubMed  Article  Google Scholar 

  69. Ang DC, Choi H, Kroenke K, Wolfe F. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J Rheumatol. 2005;32:1013–9.

    PubMed  Google Scholar 

  70. Escalante A, del Rincon I, Mulrow CD. Symptoms of depression and psychological distress among Hispanics with rheumatoid arthritis. Arthritis Care Res. 2000;13:156–67.

    PubMed  Article  CAS  Google Scholar 

  71. Margaretten M, Yelin E, Imboden J, et al. Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis. Arthritis Rheum. 2009;61:1586–91.

    PubMed  Article  CAS  Google Scholar 

  72. •• Margaretten M, Barton J, Julian L, et al. Socioeconomic determinants of disability and depression in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2011;63:240–6. In this study, the authors investigated the relationship between RA, depression, race, socioeconomic status, site of health care, and function in RA patients at two clinics (university and public). Depressed RA patients were more likely to be a member of a racial/ethnic minority group, attend the public clinic, not be on a DMARD, and have increased functional disability.

    Article  CAS  Google Scholar 

  73. Cook A, Grothaus CT, Gutierrez CE, Kehoe KA, Valentin MR. Closing the gap "Disparity in native Hawaiian cardiac care.". Hawaii Med J. 2010;69 Suppl 2:7–10.

    PubMed  Google Scholar 

  74. Chen LM, Li G, Reitzel LR, et al. Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care. Cancer Prev Res (Phila). 2009;2:782–91.

    Article  Google Scholar 

  75. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320:569–72.

    PubMed  Article  CAS  Google Scholar 

  76. Staten LK, Cutshaw CA, Davidson C, Reinschmidt K, Stewart R, Roe DJ. Effectiveness of the Pasos Adelante chronic disease prevention and control program in a US–Mexico border community, 2005–2008. Prev Chronic Dis. 2012;9:E08.

    PubMed  Google Scholar 

  77. O'Brien MJ, Halbert CH, Bixby R, Pimentel S, Shea JA. Community health worker intervention to decrease cervical cancer disparities in Hispanic women. J Gen Intern Med. 2010;25:1186–92.

    PubMed  Article  Google Scholar 

  78. Holt CL, Wynn TA, Litaker MS, Southward P, Jeames S, Schulz E. A comparison of a spiritually based and non-spiritually based educational intervention for informed decision making for prostate cancer screening among church-attending African-American men. Urol Nurs. 2009;29:249–58.

    PubMed  Google Scholar 

  79. Kenya S, Chida N, Symes S, Shor-Posner G. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature. HIV Med. 2011;12:525–34.

    PubMed  Article  CAS  Google Scholar 

  80. Esselens G, Westhovens R, Verschueren P. Effectiveness of an integrated outpatient care programme compared with present-day standard care in early rheumatoid arthritis. Musculoskelet Care. 2009;7:1–16.

    Article  Google Scholar 

  81. Vliet Vlieland TP, Hazes JM. Efficacy of multidisciplinary team care programs in rheumatoid arthritis. Semin Arthritis Rheum. 1997;27:110–22.

    PubMed  Article  CAS  Google Scholar 

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Acknowledgment

The authors would like to thank Dr. C. Kent Kwoh, MD for providing excellent comments in his review of an earlier draft of our manuscript.

Disclosure

Dr. Vina is the recipient of the American College of Rheumatology/Research and Education Foundation Scientist Development Award, which partially supports his salary and research. Dr. McBurney reported no potential conflicts of interest relevant to this article.

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Affiliations

  1. Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace St., S720A BST, Pittsburgh, PA, 15261, USA

    Christine A. McBurney & Ernest R. Vina

  2. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 7180 Highland Dr. (151C-H), Pittsburgh, PA, 15206, USA

    Ernest R. Vina

  3. Arthritis Research Center, 3347 Forbes Ave., Ste. 220, Pittsburgh, PA, 15213, USA

    Ernest R. Vina

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  1. Christine A. McBurney
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  2. Ernest R. Vina
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Correspondence to Ernest R. Vina.

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McBurney, C.A., Vina, E.R. Racial and Ethnic Disparities in Rheumatoid Arthritis. Curr Rheumatol Rep 14, 463–471 (2012). https://doi.org/10.1007/s11926-012-0276-0

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Keywords

  • Rheumatoid arthritis
  • Health disparities
  • Race
  • Ethnicity
  • Socioeconomic status
  • Patient–provider communication
  • Health literacy
  • Depression
  • Treatment
  • Adherence