Global Rural and Remote Patients with Rheumatoid Arthritis: A Systematic Review of Disease Epidemiology, Clinical Outcomes and Health Service Utilization

Background: Rural and remote patients with rheumatoid arthritis (RA) are at risk for inequities in health outcomes based on differences in physical environments and healthcare access potential compared to urban populations. The aim of this systematic review was to synthesize epidemiology, clinical outcomes and health service use reported for global populations with RA residing in rural/remote locations. Methods: Medline, EMBASE, Healthstar, CINAHL and Cochrane were searched from inception to June 2019 using librarian-developed search terms for RA and rural/remote populations. Peer-reviewed published manuscripts were included if they reported on epidemiology, clinical or health service use outcomes. Findings: Fifty-four articles were included for data synthesis, representing studies from all continents. In 11 studies where there was an appropriate urban population comparator, rural/remote populations were not at increased risk for RA, 1 study reported increased and 5 studies reported decreased prevalence in rural/remote populations. Clinical characteristics of rural/remote populations in studies with an appropriate urban comparator showed no significant differences in disease activity measures or disability, but 1 study reported worse physical function and health-related quality of life in rural/remote populations. Studies reporting on health service use provided evidence that rural/remote residence adversely impacts diagnostic time, ongoing follow-up, access to RA-care related practitioners and services, and variation in medication access and use. Interpretation: This synthesis highlights that RA epidemiology and clinical outcomes are not necessarily different between rural/remote and urban populations; however, rural/remote patients face greater barriers to care, which increases the risk for inequities in outcomes. Funding Statement: Pianarosa was supported by a Canadian Institutes of Health Research (CIHR) Institute of Musculoskeletal Health and Arthritis (IMHA) Undergraduate Summer Studentship; Chomistek is supported by an Alberta Children’s Hospital Graduate Award; Umaefulam is supported by a University of Calgary Eyes High Postdoctoral Scholarship; Barnabe is supported by a CIHR Canada Research Chair (Tier 2) in Rheumatoid Arthritis and Autoimmune Diseases, and a CIHR Foundation Scheme Grant. Declaration of Interests: The authors declare no competing interests.