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Inequity in access to bDMARD care and how it influences disease outcomes across countries worldwide: results from the METEOR-registry
  1. Sytske Anne Bergstra1,
  2. Jaime C Branco2,3,
  3. David Vega-Morales4,
  4. Karen Salomon-Escoto5,
  5. Nimmisha Govind6,
  6. Cornelia F Allaart1,
  7. Robert B M Landewé7,8
  1. 1 Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2 Department of Rheumatology, CEDOC, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
  3. 3 CHLO, EPE-Hospital Egas Moniz, Lisbon, Portugal
  4. 4 Department of Rheumatology, Universidad Autonoma de Nuevo Leon, San Nicolas de los Garza, Mexico
  5. 5 Rheumatology Center, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  6. 6 Department of Rheumatology, University of the Witwatersrand, Johannesburg, South Africa
  7. 7 Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
  8. 8 Zuyderland Medical Center, Heerlen, The Netherlands
  1. Correspondence to Sytske Anne Bergstra, Department of Rheumatology, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands; s.a.bergstra{at}


Objective To establish in a global setting the relationships between countries’ socioeconomic status (SES), measured biological disease modifying antirheumatic drug (bDMARD)-usage and disease outcomes. To assess if prescription and reimbursement rules and generic access to medication relates to a countries’ bDMARD-usage.

Methods Data on disease activity and drug use from countries that had contributed at least 100 patients were extracted from the METEOR database. Mean disease outcomes of all available patients at the final visit were calculated on a per-country basis. A questionnaire was sent to at least two rheumatologists per country inquiring about DMARD-prices, access to treatment and valid regulations for prescription and reimbursement.

Results Data from 20 379 patients living in 12 different countries showed that countries’ SES was positively associated with measured disease activity (meanDAS28), but not always with physical functioning (HAQ-score). A lower country’s SES, stricter rules for prescription and reimbursement of bDMARDs as well as worse affordability of bDMARDs were associated with lower bDMARD-usage. bDMARD-usage was negatively associated with disease activity (although not with physical functioning), but the association was moderate at best.

Conclusions Disease activity in patients with rheumatoid arthritis as well as bDMARD-usage varies across countries worldwide. The (negative) relationship between countries’ bDMARD-usage and level of disease activity is complex and under the influence of many factors, including—but not limited to—countries’ SES, affordability of bDMARDs and valid prescription and reimbursement rules for bDMARDs.

  • rheumatoid arthritis
  • disease activity
  • economic evaluations
  • DMARDs (biologic)
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  • Handling editor Josef S Smolen

  • Contributors SAB, CFA and RBML contributed to the design, analysis and interpretation of the data. JCB, DV-M, KS-E, NG and CFA contributed to the acquisition of data. SAB drafted the work. All authors revised the manuscript and read and approved the final version of the document.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The METEOR registry contains completely anonymised data which was gathered during daily practice. Treatment, timing of follow-up visits and measurements were unprotocolled. Therefore, medical ethics board approval was not required.

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

  • Data sharing statement The dataset used and analysed during the current study are available from the corresponding author on reasonable request.

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