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Extended report
Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST–RA database
  1. T Sokka1,
  2. H Kautiainen2,
  3. T Pincus3,
  4. S Toloza4,
  5. G da Rocha Castelar Pinheiro5,
  6. J Lazovskis6,
  7. M L Hetland7,
  8. T Peets8,
  9. K Immonen9,
  10. J F Maillefert10,
  11. A A Drosos11,
  12. R Alten12,
  13. C Pohl12,
  14. B Rojkovich13,
  15. B Bresnihan14,
  16. P Minnock15,
  17. M Cazzato16,
  18. S Bombardieri16,
  19. S Rexhepi17,
  20. M Rexhepi17,
  21. D Andersone18,
  22. S Stropuviene19,
  23. M Huisman20,
  24. S Sierakowski21,
  25. D Karateev22,
  26. V Skakic23,
  27. A Naranjo24,
  28. E Baecklund25,
  29. D Henrohn25,
  30. F Gogus26,
  31. H Badsha27,
  32. A Mofti28,
  33. P Taylor29,
  34. C McClinton29,
  35. Y Yazici3
  1. 1
    Jyväskylä Central Hospital, Jyväskylä; Medcare Oy, Äänekoski, Finland
  2. 2
    Unit of Family Practice, Jyväskylä Central Hospital, Jyväskylä, and ORTON, Rehabilitation Unit, Helsinki, Finland
  3. 3
    NYU Hospital for Joint Diseases, New York, NY, USA
  4. 4
    Hospital San Juan Bautista, Catamarca, Argentina
  5. 5
    Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
  6. 6
    Riverside Professional Center, Sydney, NS, Canada
  7. 7
    Copenhagen Univ Hospital at Hvidovre, Hvidovre, Denmark
  8. 8
    East-Tallinn Central Hospital, Tallinn, Estonia
  9. 9
    North Karelia Central Hospital, Joensuu, Finland
  10. 10
    Dijon University Hospital, University of Burgundy and INSERM U887, Dijon, France
  11. 11
    University of Ioannina, Ioannina, Greece
  12. 12
    Schlosspark-Klinik, Berlin, Germany
  13. 13
    Polyclinic of the Hospitaller Brothers of St. John of God in Budapest, Budapest, Hungary
  14. 14
    St. Vincent University Hospital, Dublin, Ireland
  15. 15
    Our Lady's Hospice, Dublin, Ireland
  16. 16
    Santa Chiara Hospital, Pisa, Italy
  17. 17
    Rheumatology Department, Pristine, Kosovo
  18. 18
    Pauls Stradina Clinical University Hospital, Riga, Latvia
  19. 19
    Institute of Experimental and Clinical Medicine at Vilnius University, Vilnius, Lithuania
  20. 20
    Sint Franciscus Gasthuis Hospital, Rotterdam, Netherlands
  21. 21
    Medical University in Bialystok, Bialystok, Poland
  22. 22
    Early Arthritis Department, Institute of Rheumatology of Russian Academy of Medical Sciences, Moscow, Russia
  23. 23
    Rheumatology Institut, Niska Banja, Serbia
  24. 24
    Hospital de Gran Canaria Dr. Negrin, Las Palmas, Spain
  25. 25
    Uppsala University Hospital, Uppsala, Sweden
  26. 26
    Gazi University Medical Faculty, Ankara, Turkey
  27. 27
    Dubai Bone and Joint Center, Dubai, United Arab Emirates
  28. 28
    American Hospital Dubai, Dubai, United Arab Emirates
  29. 29
    University Medical Faculty, Charing Cross Hospital, London, UK
  1. Correspondence to Dr T Sokka, Arkisto/Tutkijat, Jyväskylä Central Hospital, 40620 Jyväskylä, Finland; tuulikki.sokka{at}


Objective: To analyse associations between the clinical status of patients with rheumatoid arthritis (RA) and the gross domestic product (GDP) of their resident country.

Methods: The Quantitative Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST–RA) cohort includes clinical and questionnaire data from 6004 patients who were seen in usual care at 70 rheumatology clinics in 25 countries as of April 2008, including 18 European countries. Demographic variables, clinical characteristics, RA disease activity measures, including the disease activity score in 28 joints (DAS28), and treatment-related variables were analysed according to GDP per capita, including 14 “high GDP” countries with GDP per capita greater than US$24 000 and 11 “low GDP” countries with GDP per capita less than US$11 000.

Results: Disease activity DAS28 ranged between 3.1 and 6.0 among the 25 countries and was significantly associated with GDP (r  =  −0.78, 95% CI −0.56 to −0.90, r2  =  61%). Disease activity levels differed substantially between “high GDP” and “low GDP” countries at much greater levels than according to whether patients were currently taking or not taking methotrexate, prednisone and/or biological agents.

Conclusions: The clinical status of patients with RA was correlated significantly with GDP among 25 mostly European countries according to all disease measures, associated only modestly with the current use of antirheumatic medications. The burden of arthritis appears substantially greater in “low GDP” than in “high GDP” countries. These findings may alert healthcare professionals and designers of health policy towards improving the clinical status of patients with RA in all countries.

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Supplementary materials


  • A supplemental file of QUEST-RA collaborators is published online only at

  • Funding TS has received grants from Central Finland Health Care District and Heinola Rheumatism Foundation Hospital (EVO grants). Funding sources did not participate in the study design and the collection, management, analysis and interpretation of data, and preparation, review, or approval of the manuscript and the decision to submit it for publication.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent Obtained.

  • Contributors Study design: TS, TP, HK. Acquisition of data: The entire QUEST–RA study group. Analyses and interpretation of data: TS, HK, TP. Preparation of the manuscript and approval of the final version: The entire QUEST–RA study group. All researchers had access to all the data. TS takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Ethics approval The study was carried out in compliance with the Helsinki Declaration. Ethics Committees or Internal Review Boards of participating institutes approved the study.

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