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Individual-level and country-level socioeconomic determinants of disease outcomes in SpA: multinational, cross-sectional study (ASAS-COMOSPA)
  1. Polina Putrik1,
  2. Sofia Ramiro2,
  3. Anna Moltó3,
  4. Andras P Keszei4,
  5. Sam Norton5,
  6. Maxime Dougados3,
  7. Désirée van der Heijde6,
  8. Robert B M Landewé6,7,
  9. Annelies Boonen1
  1. 1 Rheumatology, Maastricht University Medical Center and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
  2. 2 Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  3. 3 Rheumatology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, and INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris Descartes University, Paris, France
  4. 4 Medical Informatics, Uniklinik RWTH Aachen University, Aachen, Germany
  5. 5 Academic Rheumatology Department, King’s College London, London, UK
  6. 6 Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands
  7. 7 Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
  1. Correspondence to Dr Polina Putrik, Rheumatology, Maastricht University Medical Center and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht 6202 AZ, The Netherlands; polina.putrik{at}


Objective To explore the independent contribution of individual-level and country level socioeconomic status (SES) determinants to disease activity and physical function in patients with spondyloarthritis (SpA).

Methods Data from the cross-sectional, multinational (n=22 countries worldwide) COMOSPA (COMOrbidities in SpA) study were used. Contribution of individual SES factors (gender, education) and country of residence to Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Functional Index (BASFI) was explored in multilevel regression models, adjusting for clinical and demographic confounders. Next, the additional effects of national macroeconomic indicators (gross domestic product [GDP], Human Development Index, healthcare expenditure and Gini index) were explored. The mediating role of uptake of biologic disease-modifying antirheumatic drugs between education or GDP and ASDAS was explored by testing indirect effects.

Results In total, 3370 patients with SpA were included: 65% were male, with a mean age of 43 (SD 14), ASDAS of 2.0 (SD 1.1) and BASFI score of 3.1 (SD 2.7). In adjusted models, patients with low education and female patients had an OR of 1.7 (95% CI 1.3 to 2.2) and an OR of 1.7 (95% CI 1.4 to 2.0), respectively, of having ASDAS ≥2.1. They also reported slightly worse function. Large country differences were observed independent of individual SES and clinical confounders. Patients from less SES developed countries have worse ASDAS, while patterns for BASFI were insignificant. Uptake of biologicals did not mediate the relationship between individual-level or country-level SES and disease activity.

Conclusions Individual-level and country-level health inequalities exist also among patients with SpA. Women and lower educated persons had worse disease activity and somewhat worse physical function. While patients in less socioeconomically developed countries had higher disease activity, they reported similar physical function.

  • spondyloarthritis
  • disease activity
  • epidemiology

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  • Handling editor Josef S Smolen

  • Contributors AB, RBML and DvdH have conceived the idea. PP has performed the analyses and drafted the first version. APK and SN provided statistical advice. All authors have contributed to the analyses and interpretation, as well as read and approved the final version of the manuscript.

  • Funding The COMOSPA study was conducted with the financial support from AbbVie, Pfizer and UCB, which provided an unrestricted grant to ASAS to fund the study. The funders did not have any role in the design or conduct of the study. This ancillary study did not receive any funding, and the sponsors of COMOSPA did not have any interference with this current study.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval All local ethics committees approved the COMOSPA study protocol and all patients gave their informed consent upon participation.

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