Area of Residence and Socioeconomic Factors Reduce Access to Biologics for Rheumatoid Arthritis Patients in Romania

Impact of socioeconomic status on biologics utilization in rheumatoid arthritis: revealing inequalities and healthcare efficiency

BACKGROUND/AIMS

This cross-sectional study aimed to investigate biologics treatment disparities in rheumatoid arthritis (RA) patients based on socioeconomic status (SES).

METHODS

Data from the KOrean Observational Study Network for Arthritis (KORONA) database were analyzed to assess various factors associated with SES, health behaviors, and biologics use. Logistic regression and structured equation modeling (SEM) were utilized for data analysis.

RESULTS

Among 5,077 RA patients included, 393 (7.7%) patients were identified as biologics users. Within the entire cohort, 31.8% of the participants were in the low-income and low-education groups, and 39.3% of the participants were in the high-income and high-education groups. Despite the patients with low income or low education experienced higher disease activity at diagnosis, had more comorbidities, exhibited higher medication compliance, underwent more check-ups, and had more hospital admissions than their counterparts, the odds of patients with low-income receiving biologics were 34% lower (adjusted odds ratio = 0.76, 95% confidence interval: 0.60-0.96, p = 0.021) after adjustment for demographics and comorbidities. SEM and pathway analyses confirmed the negative impact of low SES on biologics use.

CONCLUSION

The findings suggest that SES plays a significant role in biologics use among RA patients, indicating potential healthcare inefficiencies for low SES patients. Moreover, adverse healthcare habits negatively affect biologics use in RA patients. The study highlights the importance of considering socioeconomic factors while discussing biologics use and promoting equitable access to biologics for optimal RA management.

Using Potential Years of Life Lost (PYLL) to Compare Premature Mortality between Romanian Counties to Confirmed COVID-19 Cases in 2020 and 2021

This article examines the impact of the COVID-19 pandemic on potential years of life lost (PYLL) in Romania's counties in 2020 and 2021. PYLL highlights the burden of premature deaths in a community and is a useful tool for prioritizing community health issues. The study compares the PYLL variation between different counties, identifying disparities in premature mortality rates and highlighting areas that require specific public health interventions. The results indicate that COVID-19 has had a significant impact on potential years of life lost across the country. For the year 2020, the total number of deaths from confirmed COVID-19 cases was 19,455, of which 14,152 premature deaths caused 193,489 PYLL, with a crude rate of 1053.28 PYLL per 100,000 inhabitants. In 2021, there were 39,966 deaths from confirmed COVID-19 cases, with 28,777 premature deaths, 386,061 PYLL, and a crude rate of 2116.63 PYLL per 100,000 population. This study reveals significant variations only in some counties, based on BYLL rates, and in the two years analyzed. The proportion of premature deaths (<80 years) varied by county and gender. PYLL's analysis by gender shows that men experienced a higher number of premature deaths than women in most counties, and this trend persisted in both years. The results are presented in the form of thematic maps, highlighting standardized PYLL rates for both genders in each county, facilitating a visual understanding of regional disparities. The identified variations can serve as a basis for developing and implementing more effective public health policies, based on the specifics of each county.

Splenectomy at early stage of autoimmune arthritis delayed inflammatory response and reduced joint deterioration in mice

The spleen plays a role in innate and adaptive immunity, and autoimmune diseases like rheumatoid arthritis (RA). We investigated the effect of splenectomy in early and moderate stages of autoimmune arthritis in a mouse model. To induce recombinant human G1-induced arthritis (GIA), BALB/c mice were immunized intraperitoneally three times in 4-week intervals with the rhG1 antigen. Mice were splenectomized on day 7 (SPE1) or day 35 (SPE2) after the initiation of immunization; tested for clinical severity, joint radiological and histological changes, serum levels of inflammatory cytokines and autoantibodies, and rhG1-specific immune responses; and compared to those in control mice with spleen left intact. Circulating Tregs and T-helper subset ratios in the spleen and inguinal lymph nodes (LNs) were also examined using flow cytometry. The onset of severe inflammatory response was significantly delayed in SPE1 and SPE2 groups compared to control mice at early stages of GIA, which was associated with increased circulating Tregs. After the third immunization, as disease progressed, the severity scores were robustly increased in all mice. Nevertheless, in splenectomized mice, we observed reduced joint deterioration and cartilage damage, more Th2 cells in LNs, and reduced levels of pro-inflammatory cytokines and autoantibodies in their sera. Mesenteric LN cells of splenectomized mice exhibited weaker response in vitro against the rhG1 antigen compared to control mice spleen. In conclusion, splenectomy in the early stages of GIA delayed the inflammatory response, suggesting a protective effect against the development and progression of severe destructive arthritis.

Socioeconomic Status and Medication Use in Rheumatoid Arthritis: A Scoping Review

OBJECTIVE

Socioeconomic status (SES) influences disease outcomes in rheumatoid arthritis (RA) patients. Differences in medication use may partly explain this association. A scoping review was used to identify research conducted on this topic and determine what knowledge gaps remain.

METHODS

Medline, Embase, and PsychInfo were searched from their inception until February 2022 for studies that assessed SES and medication use as an outcome variable. Data was extracted on the use of specific SES measures, medication use, and whether differences in SES variables were associated with differences in medication use.

RESULTS

We identified 2,103 studies, of which 81 were selected for inclusion. Included studies originated most frequently from the US (42%); the mean ± SD age of participants was 55.9 ± 6.8 years, and most were female (75%). Studies measured a median of 4 SES variables (interquartile range 3-6), with educational, area-level SES, and income being the most frequent measurements used. Patients' race and/or ethnicity were documented by 34 studies. Studies primarily assessed the likelihood of prescription of disease-modifying antirheumatic drugs or dispensation, medication adherence, or treatment delays. A majority of studies documented at least 1 SES measure associated with a difference in medication use.

CONCLUSION

There is some evidence that SES affects use of medications in patients with RA; however, multiple definitions of SES have been utilized, making comparisons between studies difficult. Prospective studies with consistently defined SES will be needed to determine whether differences in medication use accounts for the poorer outcomes experienced by patients of lower SES.

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran’s I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.

The Economic Impact of Originator-to-Biosimilar Non-medical Switching in the Real-World Setting: A Systematic Literature Review

INTRODUCTION

To save costs to the healthcare system, forced non-medical switch (NMS) policies that cut drug coverage for originator biologics and fund only less expensive biosimilars are being implemented. However, costs related to the impact of NMS on healthcare resource utilization (HCRU) must also be considered. This study aims to summarize the evidence on the economic impact of an originator-to-biosimilar NMS.

METHODS

A systematic literature review (SLR) was conducted. Publications reporting on HCRU or costs associated with originator-to-biosimilar NMS in the real-world setting were searched in MEDLINE and EMBASE from January 2008 to February 2020. In addition to hand searching the reference lists of relevant publications and SLRs, key conference websites, PubMed, and various government sites were also searched for the 2 years preceding the search (2018-2020).

RESULTS

A total of 1845 citations were identified, of which 49 were retained for data extraction. Most studies reporting on the HCRU associated with NMS reported on post-NMS HCRU alone without a comparison pre-NMS. However, four studies described a difference in HCRU (i.e., investigations pre- vs post-switch or between non-switchers vs switchers), all of which reported a relative increase in HCRU, including laboratory testing, imaging, medical visits, and hospitalizations, amongst patients who underwent an originator-to-biosimilar NMS. Most studies reporting on the costs associated with NMS reported significant savings following NMS on the basis of drug costs alone. However, four studies specifically reporting on the difference of costs following originator-to-biosimilar NMS all demonstrated an increase in HCRU-related costs associated with NMS (increase in HCRU-related costs of 4-37% or 148-2234 2020 Canadian dollars).

CONCLUSION

Amongst the studies that reported on the difference in HCRU pre- vs post-switch or between non-switchers and switchers, all showed an increase in HCRU and related costs associated with NMS, suggesting that the expected overall savings due to less costly drug prices may be reduced as a result of an increase in HCRU and its associated costs post-switch. Nevertheless, more real-world studies that include NMS-related healthcare costs in addition to drug costs are needed.

Global Rural and Remote Patients with Rheumatoid Arthritis: A Systematic Review

Objective

Rural and remote patients with rheumatoid arthritis (RA) are at risk for inequities in health outcomes based on differences in physical environments and health care access potential compared to urban populations. The aim of this systematic review was to synthesize epidemiology, clinical outcomes, and health service use reported for global populations with RA residing in rural and remote locations.

Methods

Medline, Embase, HealthStar, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library were searched from inception to June 2019 using librarian‐developed search terms for RA and rural and remote populations. Peer‐reviewed published manuscripts were included if they reported on epidemiologic, clinical, or health service use outcomes.

Results

Fifty‐four articles were included for data synthesis, representing studies from all continents. In 11 studies in which there was an appropriate urban population comparator, rural and remote populations were not at increased risk for RA; 1 study reported increased prevalence, and 5 studies reported decreased prevalence in rural and remote populations. Clinical characteristics of rural and remote populations in studies with an appropriate urban comparator showed no significant differences in disease activity measures or disability, but 1 study reported worse physical function and health‐related quality of life in rural and remote populations. Studies reporting on health service use provided evidence that rural and remote residence adversely impacts diagnostic time, ongoing follow‐up, access to RA‐care–related practitioners and services, and variation in medication access and use, with prominent heterogeneity noted between countries.

Conclusion

RA epidemiology and clinical outcomes are not necessarily different between rural/remote and urban populations within countries. Rural and remote patients face greater barriers to care, which increases the risk for inequities in outcomes.

Impact of COVID-19 pandemic on rheumatoid arthritis from a Multi-Centre patient-reported questionnaire survey: influence of gender, rural-urban gap and north-south gradient

During the coronavirus disease-2019 (COVID-19) pandemic there were several barriers to treatment access and medication adherence in rheumatoid arthritis (RA) patients. There is no information regarding the RA patient health status in Egypt during the COVID-19. Thus,the aim of this work was to study the impact of the pandemic on RA patients through a patient-reported questionnaire and to determine the influence of gender, geographic regions. This multi-centre study initiated by the Egyptian College of Rheumatology (ECR) was conducted on 1037 RA patients attending rheumatology clinics from 10 governorates. The questionnaire provided covered socio-demographic data, health/disease status, information/knowledge about COVID-19 and medical/family history of the infection. Patients mean age was 44.2 ± 12.3 years;855 females and 182 males; 539(52%) from rural and 497(48%) from urban areas. 41.8% reported a striking difficulty to obtain hydroxychloroquine during the pandemic. The majority (70%) considered maintaining a regular visit to the rheumatologist in addition to remote contact mainly by phone (44.4%) or via WhatsApp (33.1%), in particular among male and urban patients. Urban patients were more likely to be infected by COVID-19 (12.9% vs 6.2%; p < 0.0001) than rural. Northern cities had more patients with suspected COVID-19 (13.9% vs 6.1%; p < 0.0001); was significantly associated with more disease flares (30.8% vs 5.8%) with subsequent change in the RA treatment (20.9% vs 6.4%; p < 0.0001). Patients with RA faced remarkable difficulty to obtain their medications with subsequent change in their disease status. The challenges of the pandemic have hastened changes in the way we deliver health care.

Accessibility to biologics and its impact on disease activity and quality of life in patients with rheumatoid arthritis in Kuwait

Objective

Biologics are indicated in rheumatoid arthritis (RA) in case of persistent high disease activity despite conventional disease-modifying anti-rheumatic drugs (cDMARDs) or patients with contraindications to cDMARDs or poor prognostic factors. The purpose of this study was to compare the prescription rates of biologics in Kuwaiti and non-Kuwaiti patients and to assess whether this had an impact on disease activity and quality of life in RA patients.

Methods

Data were extracted from the Kuwait Registry for Rheumatic Diseases. Adult patients who satisfied the ACR classification criteria for RA from four major hospitals in Kuwait were evaluated from February 2013 through May 2018. The treatment agents, disease activity, and quality of life of Kuwaiti patients were compared with non-Kuwaiti patients.

Results

A total of 1651 RA patients were included; 806 (48.8%) were Kuwaiti patients. Among Kuwaiti patients, 62.5% were on biologic drugs in comparison with 14% of non-Kuwaiti patients. In comparison with non-Kuwaiti patients, Kuwaiti patients had significantly lower numbers of swollen joints (p < 0.001) and disease activity score-28 scores (p = 0.02) and less steroid use (p < 0.001) yet a significantly higher health assessment questionnaire-disability index (p < 0.001). Regression analysis showed that DAS-28 scores were significantly associated with the treatment type (p < 0.001) and that nationality was significantly predictive of the treatment type (p < 0.001).

Conclusion

In the setting of easy accessibility to treatment for Kuwaiti patients, biologics were prescribed by rheumatologists at a higher rate than for non-Kuwaitis. This may explain the lower disease activity and the lower rate of steroid use in Kuwaiti patients than non-Kuwaitis.

Key points

• Significant discrepancies in the rates of prescribing biologic therapies between KP and NKP in Kuwait were observed.

• Several treatment outcomes were significantly better in the KP group than in the NKP group even after adjustment of confounding factors.

• The poor access to biologic therapies was suggested to limit the effectiveness of RA treatments in the NKP group.

Identifying Patient Access Barriers for Tumor Necrosis Factor Alpha Inhibitor Treatments in Rheumatoid Arthritis in Five Central Eastern European Countries

Introduction

Although there is a significant utilization gap of biologic medicines in the EU, many studies estimate equity in patient access to biopharmaceuticals only based on their availability on the national list of reimbursed medicines. Hidden access barriers may facilitate financial sustainability of pharmaceuticals in less affluent EU countries; however, they have rarely been documented in scientific publications. Our objective was to explore these access barriers for tumor necrosis factor (TNF) alpha inhibitors in rheumatoid arthritis (RA) in five Central and Eastern European countries.

Methods

A detailed interview guide was developed based on multi-stakeholder workshops and a targeted literature review. In each participant country 3-3-3-3 interviews with payers, rheumatologists, patients/patient representatives, and industry representatives were conducted. Responses were aggregated at a country level and validated by primary investigators in each country.

Results

Limited number of RA centers and consequently significant travelling time and cost for patients in distant geographical areas, uneven budget allocation among centers, limited capacity of nurses, narrowed patient population in national financial protocols compared to international clinical guidelines in initiating or continuing biologics, high administrative burden in prescribing biologics and limited health literacy of patients were the most relevant barriers to timely patient access in at least three participant countries.

Conclusion

Assessing only the availability of TNF alpha inhibitors on the national list of reimbursed medicines provides limited information about real-world patient access to these medicines. Revealing hidden access barriers may contribute to initiate policy actions which could reduce inequity in patient access.

Analysis of the Indirect Costs of Rheumatoid Arthritis in Romania

Rheumatoid arthritis (RA) is associated with increased costs generated by resource utilization and loss of work productivity. We have studied 206 RA patients and analyzed indirect costs of RA in Romania (estimated using the human capital approach) in comparison with reported data for other countries. Data were collected using self-reported questionnaires. The average age at inclusion was 55 years, with mean disease duration of 9.4 years; 55 patients had permanent work disability due to RA; 6.35 days of sick leave per patient were reported for the entire year of follow-up; the cost of permanent work disability was 1256€ per patient. From a societal perspective, the average indirect costs for a patient with RA were 1506€, significantly lower than the ones reported by other countries, especially due to the low monetary value of paid work.

Biological Therapies in Immune-Mediated Inflammatory Diseases: Can Biosimilars Reduce Access Inequities?

Biological therapies are an effective treatment for a range of immune-mediated inflammatory diseases (IMIDs), including rheumatoid arthritis, psoriasis, and inflammatory bowel diseases. However, due to their high costs, considerable differences in their utilization exist across the world, even among the various European countries, with many countries restricting access despite professional society guideline recommendations. Adoption of biologics by healthcare providers has been particularly poor in many Central and Eastern European countries. Differences in utilization have also been observed across medical specialties, healthcare providers, and at a regional and national level. The objective of this paper is to provide an overview of the different market access policies for biologics in Europe and to investigate reasons for such differences. One of the potential solutions for providing broader access to IMID patients, where cost is the major barrier, is to encourage the use of biosimilars in place of their reference products. Biosimilars are generally less expensive alternatives to already licensed biological therapies and are approved on the basis that they are similar to the reference product in terms of quality, safety, and efficacy. Budget impact models predict considerable cost savings following the introduction of biosimilars in the next few years. These savings could be used to increase access to biologics and other innovative therapies.