Differences in Disease Outcomes Between Medicaid and Privately Insured Children: Possible Health Disparities in Juvenile Rheumatoid Arthritis HERMINE I. BRUNNER, JANALEE TAYLOR, MARIA T. BRITTO, MELINDA S. CORCORAN, SANDY L. KRAMER, PAULA G. MELSON, UMA R. KOTAGAL, T. BRENT GRAHAM, AND MURRAY H. PASSO Objective. To determine the relationship between health insurance status and disease outcome in children with juvenile rheumatoid arthritis (JRA). Methods. JRA patients followed at a tertiary pediatric rheumatology center were assessed for the number of active joints and number of joints with limited range of motion. Disease activity, patient well-being, and pain were measured. Disability was assessed by the Childhood Health Assessment Questionnaire, health-related quality of life by the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale, and the PedsQL Rheumatology Module. Health care resource utilization was estimated based on the number of billing events for health services coded in administrative databases; these databases also provided information on patient health insurance status. Children insured by Medicaid or similar state programs for low-income families were considered to have Medicaid status. Disease outcomes of children with Medicaid status was compared with that of children with private health insurance. Results. Forty (14%) of the 295 children with JRA had Medicaid status. Patients with Medicaid status were more often of nonwhite race (P < 0.04) and more frequently had a polyarticular or systemic disease course (P  0.04) compared with other patients (n  255). After correction for differences in disease duration, race, JRA onset, and JRA course between groups, children with Medicaid status continued to have significantly higher disability (P < 0.0003), and lower mean PedsQL Generic Core Scale scores (P < 0.05), while health resource utilization appeared similar between groups. Conclusion. Despite apparently similar health resource utilization and joint involvement, Medicaid status is associated with significantly lower health-related quality of life and higher disability in JRA. KEY WORDS. Disparity; Childhood Health Assessment Questionnaire; Medicaid; Socioeconomic status; Juvenile idio- pathic arthritis; Juvenile rheumatoid arthritis; Health-related quality of life; Pediatric Quality of Life Inventory. INTRODUCTION Juvenile rheumatoid arthritis (JRA) is a group of pediatric autoimmune diseases whose hallmark is chronic inflam- mation of the joints (1). Females are more commonly di- agnosed with JRA than males (female:male ratio 3:1) and the disease is more frequent among whites than minority populations in the US (2). The estimated prevalence of JRA is 132 per 100,000 children (95% confidence interval 119 – 145 per 100,000) (3). Besides the number of involved joints during the first 6-month period after diagnosis, JRA dis- ease onset types are based on the presence of systemic disease, e.g., fever, rash, and serositis. Systemic-onset JRA is diagnosed in children with systemic disease features, irrespective of the number of involved joints; pauciarticu- lar-onset or polyarticular-onset JRA are present if 4 joints or 5 joints are involved, respectively. JRA disease course is determined by the presence of systemic features and, in the absence of systemic features, the number of involved joints 6 months after diagnosis (in pauciarticular course it is 4 involved joints, in polyarticular course it is 5 involved joints). JRA often persists into adulthood (4 –7) and is associated with increased mortality (8) as well as a large burden of disease (9 –11). Supported by grants from the Robert Wood Johnson Foun- dation, the Arthritis Foundation of America, and the Na- tional Institute of Arthritis and Musculoskeletal and Skin Diseases (P60-AR47784). Hermine I. Brunner, MD, MSc, Janalee Taylor, MSN, CNS, Maria T. Britto, MD, MP, Melinda S. Corcoran, BSEd, Sandy L. Kramer, Paula G. Melson, PT, MMSc, Uma R. Kotagal, MB, BS, MSc, T. Brent Graham, MD, MSc, Murray H. Passo, MD: Cincinnati Children’s Hospital Medical Center, Cincin- nati, Ohio. Dr. Brunner and Ms Taylor contributed equally to this work. Address correspondence to Hermine I. Brunner, MD, MSc, Cincinnati Children’s Hospital Medical Center, Uni- versity of Cincinnati, William Rowe Division of Rheumatol- ogy, E 4010, 3333 Burnet Avenue, Cincinnati, OH 45229- 3039. E-mail: hermine.brunner@cchmc.org. Submitted for publication May 12, 2005; accepted in re- vised form November 3, 2005. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55, No. 3, June 15, 2006, pp 378 –384 DOI 10.1002/art.21991 © 2006, American College of Rheumatology ORIGINAL ARTICLE 378