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Impact of socioeconomic gradients within and between countries on health of patients with rheumatoid arthritis (RA): Lessons from QUEST RA

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In this chapter, we discuss challenges in collecting data on outcomes of patients who receive usual rheumatology care. We present results of the multinational Quantitative Monitoring of Patients with Rheumatoid Arthritis (QUEST RA) study which is a successful example of quantitative clinical measuring of RA as part of routine clinical care in a large number of centres across more than 30 countries. We further elaborate on what we can learn from these data about inequalities and inequities, both within and between countries. Frameworks to understand socioeconomic determinants of health are presented and, in addition to the QUEST RA data, the literature is summarised to provide further evidence on how socioeconomic determinants can contribute to health disparities of patients within and between countries.

Introduction

Clinical management and outcomes of rheumatoid arthritis (RA) have changed over the last two decades. New potent biologic treatments came to market in the late 1990s and are now widely used. Old traditional disease-modifying anti-rheumatic drugs (DMARDs) are being used more effectively. As a result of these changes, it has been recognised that remission is possible to be reached when treating patients early and actively [1], [2]. Long-term outcomes of RA have improved compared to earlier decades concerning patient general status, disease activity, joint damage and need for joint replacements, work disability and mortality [3]. Recent guidelines and treatment recommendations emphasise early, active and continuous care of patients with RA and have been successfully communicated to rheumatology communities around the world [4]. A sense of great achievement in treatment of RA can be felt in rheumatology meetings and scientific literature.

A question remains whether this achievement is valid for all patients regardless of age, gender, race, prosperity, country of residence or economic environment. Do all patients with RA receive high quality rheumatology care in all parts of the world?

Section snippets

Challenges when collecting information on patients' health status in the usual care setting

Documentation of clinical status and outcomes of patients who receive usual clinical care in different rheumatology settings in different countries is needed for comparative studies between countries or between specific groups of patients. However, most clinical rheumatology care continues to be conducted according to physicians' impressions rather than to quantitative measures, which are used primarily in clinical trials and for research purposes. As clinical data are an essential element to

QUEST RA as an effort to collect data across countries about usual care

QUEST RA is a multinational collaboration aiming at reviewing patients with RA for their clinical status and is therefore described here as a successful example of quantitative clinical measuring of RA as part of routine clinical care. QUEST RA collects data from consecutive, unselected patients with RA with no other criteria but adult-onset RA. Three or more clinics are invited in each country, to ensure generalisability of the data. In each clinic, 100 or more patients are assessed according

Health disparities and factors that contribute to inequality. Access to health care as one of the determinants to health

Having discussed the challenges to retrieve data from routine practice in a multinational context, the interesting and following question is how we can interpret differences not only between, but also within countries. Whether people are healthy or not can partly be determined by the circumstances and the environment. This is also recognised by the World Health Organization (WHO) that distinguishes the following groups of factors as possible determinants of health: the social and economic

Comparing health status of RA patients within and between countries

While the main challenge of QUEST RA is seen in the international comparison, these data also help to shed light into possible inequalities that are universal. One of the PROGRESS measures that were explored in QUEST RA was gender and to what extent there were differences in outcomes between males and females [45]. Remissions are nowadays more frequently seen compared to earlier decades, although influenced by the definition used *[20], [46]. Some studies suggest that male gender is a major

Access to treatments of RA within and between countries as one of the determinants of health outcome

Limited evidence shows that access to rheumatologic care varies between countries, and disfavours lower-income countries. The majority of the evidence on this determinant concerns the access to treatments with biological DMARDs. On the availability dimension of access, Emery et al. reported already in 2009 a large variability in the eligibility criteria for the start and continuation of a biological in 11 countries from Western and Central Europe [85]. However, their study did not link these

Way forward

Although being important to identify possible causes of large-scale inequities, the reviewed studies of access to rheumatologic care on national and regional levels cannot provide full insight into the actual access for the individual. No agreed-upon methods to assess all dimensions of access are available, and most existing studies ignore the extent to which patient characteristics, such as socioeconomic determinants, health literacy and health beliefs influence access. Last but not the least,

References (103)

  • J.S. Smolen et al.

    EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs

    Annals of the Rheumatic Diseases

    (2010 Jun)
  • R. Harbour et al.

    A new system for grading recommendations in evidence based guidelines

    British Medical Journal

    (2001 Aug 11)
  • T.K. Kvien et al.

    Criteria for TNF-targeted therapy in rheumatoid arthritis: estimates of the number of patients potentially eligible

    Drugs

    (2001)
  • T. Sokka et al.

    Eligibility of patients in routine care for major clinical trials of anti-tumor necrosis factor alpha agents in rheumatoid arthritis

    Arthritis & Rheumatism

    (2003 Feb)
  • F. Gogus et al.

    Inclusion criteria as widely used for rheumatoid arthritis clinical trials: patient eligibility in a Turkish cohort

    Clinical and Experimental Rheumatology

    (2005 Sep–Oct)
  • D.T. Felson et al.

    The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials

    Arthritis & Rheumatism

    (1993 Jun)
  • D.M. van der Heijde et al.

    Development of a disease activity score based on judgment in clinical practice by rheumatologists

    Journal of Rheumatology

    (1993 Mar)
  • M.L. Prevoo et al.

    Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis

    Arthritis & Rheumatism

    (1995 Jan)
  • D. Aletaha et al.

    The Simplified disease activity index (SDAI) and the clinical disease activity index (CDAI): a review of their usefulness and validity in rheumatoid arthritis

    Clinical and Experimental Rheumatology

    (2005 Sep–Oct)
  • T. Pincus et al.

    Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count

    Annals of the Rheumatic Diseases

    (2006 Jun)
  • T. Pincus et al.

    An index of patient reported outcomes (PRO-Index) discriminates effectively between active and control treatment in 4 clinical trials of adalimumab in rheumatoid arthritis

    Journal of Rheumatology

    (2006 Nov)
  • F. Wolfe et al.

    The assessment of rheumatoid arthritis and the acceptability of self-report questionnaires in clinical practice

    Arthritis & Rheumatism

    (2003 Feb 15)
  • T. Pincus

    Documenting quality management in rheumatic disease: are patient questionnaires the best (and only) method?

    Arthritis Care and Research

    (1996 Oct)
  • F. Wolfe et al.

    Preliminary core set of domains and reporting requirements for longitudinal observational studies in rheumatology

    Journal of Rheumatology

    (1999 Feb)
  • T. Sokka et al.

    Remission and rheumatoid arthritis: data on patients receiving usual care in twenty-four countries

    Arthritis & Rheumatism

    (2008 Sep)
  • N.A. Khan et al.

    Patient's global assessment of disease activity and patient's assessment of general health for rheumatoid arthritis activity assessment: are they equivalent?

    Annals of the Rheumatic Diseases

    (2012 Apr 24)
  • N.A. Khan et al.

    Determinants of discordance in patients' and physicians' rating of rheumatoid arthritis disease activity

    Arthritis Care and Research (Hoboken)

    (2012 Feb)
  • T. Sokka et al.

    QUEST-RA: quantitative clinical assessment of patients with rheumatoid arthritis seen in standard rheumatology care in 15 countries

    Annals of the Rheumatic Diseases

    (2007 Nov)
  • T. Sokka et al.

    Physical inactivity in patients with rheumatoid arthritis: data from twenty-one countries in a cross-sectional, international study

    Arthritis & Rheumatism

    (2008 Jan 15)
  • A. Naranjo et al.

    Cardiovascular disease in patients with rheumatoid arthritis: results from the QUEST-RA study

    Arthritis Research and Therapy

    (2008)
  • S.M. Verstappen et al.

    Functional health assessment questionnaire (HAQ) and psychological HAQ are associated with and predicted by different factors in rheumatoid arthritis

    Journal of Rheumatology

    (2007 Sep)
  • N.A. Khan et al.

    Reevaluation of the role of duration of morning stiffness in the assessment of rheumatoid arthritis activity

    Journal of Rheumatology

    (2009 Nov)
  • T. Sokka et al.

    Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST RA database

    Annals of the Rheumatic Diseases

    (2009)
  • T. Sokka et al.

    Women, men, and rheumatoid arthritis: analyses of disease activity, disease characteristics, and treatments in the QUEST-RA study

    Arthritis Research and Therapy

    (2009)
  • CSHD

    Closing the gap in a generation: health equity through action on the social determinants of health

    (2008)
  • I. Kawachi et al.

    A glossary for health inequalities

    Journal of Epidemiology and Community Health

    (2002 Sep)
  • M. Whitehead

    The concepts and principles of equity and health

    Health Promotion International

    (1991)
  • WHO

    HIA glossary of Terms

    (2012)
  • ISEqH

    International society for equity in health. Definitions

    (2010)
  • P. Braveman et al.

    Defining equity in health

    Journal of Epidemiology and Community Health

    (2003 Apr)
  • L. Carmona et al.

    Despair on disparities

    Annals of the Rheumatic Diseases

    (2009 Nov)
  • M. Loisac et al.

    Access and choice - competition under the roof of solidarity in German health care: an analysis of health policy reforms since 2004

    Health Economics, Policy and Law

    (2009)
  • M. Gulliford et al.

    What does ‘access to health care’ mean?

    Journal of Health Services Research & Policy

    (2002 Jul)
  • R. Ayé et al.

    Illness costs to households are a key barrier to access diagnostic and treatment services for tuberculosis in Tajikistan

    BMC Research Notes

    (2010 Dec 20)
  • D. McIntyre et al.

    Access as a policy-relevant concept in low- and middle-income countries

    Health Econ Policy Law

    (2009 Apr)

  • Introduction

  • T. Evans et al.

    Road traffic crashes: operationalizing equity in the context of health sector reform

    International Journal of Injury Control and Safety Promotion

    (2003 Mar–Jun)
  • P. Tugwell et al.

    Is health equity considered in systematic reviews of the Cochrane Musculoskeletal Group?

    Arthritis & Rheumatism

    (2008 Nov 15)
  • T. Sokka

    Long-term outcomes of rheumatoid arthritis

    Current Opinion in Rheumatology

    (2009 May)
  • H. Makinen et al.

    Definitions of remission for rheumatoid arthritis and review of selected clinical cohorts and randomised clinical trials for the rate of remission

    Clinical and Experimental Rheumatology

    (2006 Nov-Dec)
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