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GDP, drug affordability impact nations' RA disease activity, biological DMARD use
Disease activity and the use of biological disease-modifying antirheumatic drugs among patients with rheumatoid arthritis vary from country to country, with many factors influencing their inverse relationship, including per capita gross domestic product, drug affordability and reimbursement rules, according to findings published in the Annals of the Rheumatic Diseases.
“Current recommendations advise starting biological DMARDs after a first conventional synthetic DMARD strategy has failed,” Sytske Ann Bergstra, MSc, of the Leiden University Medical Center in the Netherlands, told Healio Rheumatology. “Previous research showed that within Europe, differences in socioeconomic welfare were associated with differences in prescription- and reimbursement rules of biological DMARDs. This may result in more infrequent use of biological DMARDs and worse health outcomes.”
To evaluate the relationships between a nation’s socioeconomic status, use of biological DMARDs and disease outcomes, and to determine if reimbursement rules and access to drugs influences biological DMARD use, the researchers reviewed data from the Measurements of Efficacy of Treatment in the Era of Outcome in Rheumatology (METEOR) registry, an international, observational database of daily clinical practice records. For their study, the researchers focused on 20,379 patients with RA from 12 counties that had contributed at least 100 cases to the database. The countries included the United States, Mexico, South Africa, Japan, Brazil, the United Kingdom, Spain, Ireland, Portugal, France, India and the Netherlands.
Using the database, Bergstra and colleagues calculated mean disease outcomes of all available patients at the final visit. They also distributed questionnaires to at least two rheumatologists per country, asking about DMARD prices, access to treatment and all relevant rules and regulations governing prescriptions and reimbursement.
According to the researchers, a nation’s socioeconomic status was positively associated with disease activity — as measured by mean DAS28 — but not necessarily with physical function — as measured by health assessment questionnaire score. Lower socioeconomic status, stricter prescription and reimbursement regulations and higher prices for biological DMARDs were associated with lower usage. In addition, use of biological DMARDs was negatively associated with disease activity, although the link was “moderate at best,” the researchers wrote.
“We found substantial differences in DMARD prices, affordability of these medications and biological DMARD usage across countries,” Bergstra said. “Altogether, our findings point to the existence of worldwide inequity with regard to optimal access to RA health care. These findings may help policy makers to guide necessary change and rheumatologists and health care workers to help improving access to rheumatology care.” — by Jason Laday
Disclosure: Bergstra reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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The study conducted by Bergstra and colleagues sets out to establish a relationship between countries’ socioeconomic status (SES), access to the use of biologic DMARD therapies and overall disease outcomes of more than 20,000 patients with RA living in 12 different countries.
The results showed that the SES of a country positively impacted the mean DAS28 or disease activity score, but not always the HAQ-score which measures physical function. While I think it is easy to assume that the countries with a higher SES are more likely to have better access to care — thus leading to the increased use of biologic DMARDs and resulting in better disease outcomes — the study showed that this is actually a much more complex reality.
The researchers highlighted substantial differences between the prices and affordability of these medications between countries; for example, biologic DMARD prices in the United States were 5.9 times higher than prices in France. The study also demonstrated differences in the strictness of prescription and reimbursement rules among the various countries.
Overall, I think this study shows a worldwide inequity to optimal access to health care for patients with RA. With an influx of biologic DMARDS brought to the market over the past 15 years, our RA patients should have access to the proper treatment. Even in the U.S., a country with one of the highest SES among those studied, we see patients that cannot afford to or do not have access to proper RA medications. As health care providers, we need to continue to fight for better access to these medications for our patients.