Improving Care for People Living with Rheumatic Disease and Extreme Poverty: An Interim Analysis of a Prospective Study on Honorarium and Outreach Supports

Objectives Individuals living with rheumatic disease who are marginalized by extreme poverty and housing instability suffer dramatically worse outcomes.[1,2] Those living in Vancouver’s Downtown Eastside experience high rates of substance use disorder, mental illness, and early mortality.[3] Since 2019, the Mary Pack Arthritis Program has operated a twice-monthly Rheumatology Clinic (“the Clinic”) in partnership with the Pender Community Health Centre, an inner-city primary care unit. Although this Clinic has lowered barriers to accessing care, challenges remain in adherence to follow-up appointments, monitoring lab work, and sustaining DMARD therapy. Our study aimed to first review the Clinic’s service provision and subsequently design and pilot an intervention to improve patient engagement in the care of their rheumatic disease. Methods We utilized a mixed-methods approach beginning with a retrospective chart review of all patients seen at the Clinic from January 2022 until June 2025. We concurrently conducted interviews with Clinic rheumatologists, inner-city primary care physicians, and patient representatives to understand specific barriers. Based on these findings, we designed a prospective trial for patients with inflammatory arthritis referred from local inner-city community health centers. The intervention included a $20 honorarium for each follow-up visit they attended with completed bloodwork as well as a Rheumatology-specific outreach service that provided personalized education, advice, and appointment reminders. The primary outcome was the rate of attendance to follow-up visits in the study group compared to historical controls. The study was approved by the UBC REB (H24-03984). Results Between January 2022 and June 2025, the Clinic treated 167 unique patients (Table 1). The baseline rate of attendance to follow-up visits was 52.6% overall, and 42.4% among patients with a confirmed systemic autoimmune rheumatic disease. The patient population had high rates of comorbidity: 77% had substance use disorders, while 59% had mental health disorders. Housing instability was nearly universal; 12% of patients were unhoused, while 78% lived in modular, transitional, or single-room occupancy (SRO) housing. At a planned interim analysis of the prospective study (n=9), the rate of adherence to follow-up visits was significantly improved compared to historical controls (90.5% vs 42.4%, p < 0.001). For participants who were previously patients at the Clinic, follow-up rates improved compared to personal priors (87.5% vs 43.5%, p < 0.001). No concerning safety signals were identified. Conclusion Standard models of care are often insufficient for marginalized populations. An intervention combining modest financial incentives and specialized outreach support may improve adherence to follow-up in this cohort. References [1.] Rai B. Clin Rheumatol 2022;41:1653-7. [2.] Seta R. Clin Rheumatol 2020;40:413-20. [3.] Vila-Rodriquez F. Am J Psychiatry 2013;170:1413-22. Practice Reflection Award, Best Abstract on Equity Diversity and Inclusion in Rheumatology Award