背景：
生物類抗風濕類藥物（bDMARDs）在脊柱關節炎（SpA）中的價值的得到了越來越多重視，但由於經濟等因素，bDMARDs在世界範圍應用具有明顯差異。
目的：
本研究探討了不同國家和地區bDMARDs在SpA中的應用差異及社會經濟因素與其相關性。
方法：
國際性橫斷麵ASAS COMOSpA研究納入符合ASAS SpA標準的病人。以當前國家bDMARDs的應用作為有隨機截距的多水平Logistic回歸模型的因變量。國家衛生支出與國內生產總值（GDP）對社會經濟的貢獻（低、中、高3組）作為國家水平獨立影響因素，在模型中作為社會人口學因素與臨床變量一起決定bDMARD在SpA中的應用。
結果：
共3370例來自22個國家的患者符合納入標準（平均年齡：43歲；平均患病時間：14年；其中66%為男性；88%為中軸病變）。在這些國家中，共有1275例（38%）SpA患者為bDMARDs使用者。各國使用bDMARDs比例從5%（中國）到74%（比利時）不等。在調整相關社會人口和臨床變量後，各國bDMARD使用的顯著差距仍然存在（圖1，p <0.001）。 各國的社會經濟因素，尤其是較高的衛生支出與較高的bDMARD攝取有關（表1），雖然結果無統計學意義（OR 1.91; 95％CI 0.93,3.92）。 國家GDP水平也存在類似結果（OR 1.72; 95％CI 0.83,3.57）。
圖1 不同國家bDMARDs的使用率（%），基於社會經濟，社會人口和臨床變量調整模型，百分比用量顯示為95％CI
表1 國家社會經濟因素對社會人口和臨床變量調整模型中使用bDMARDs的影響（國家作為隨機效應）
結論：
在排除了臨床變量和國家間的社會因素後，各國國家間SpA患者的bDMARD使用率仍有巨大差異。
原文
INEQUITY IN BIOLOGIC DMARD PRESCRIPTION FOR SPA ACROSS THE GLOBE. RESULTS FROM THE ASAS COMOSPA STUDY.
E. Nikiphorou1,*, D. van der Heijde2, S. Norton1, R. Landewé3, A. Moltó4, M. Dougados4, F. van den Bosch5, S. Ramiro2
1KCL,London, United Kingdom, 2LUMC, Leiden, 3ARC, Amsterdam,Netherlands, 4Paris Descartes University, Paris, France, 5GhentUniversity Hospital, Ghent, Belgium
Background:
The value of biologic DMARDs (bDMARDs) in SpA is well recognized but global access to these treatments can be limited due to high cost and other factors.
Objectives:
This study explores variation in the use of bDMARDs in SpA across countries and to what extent socio-economic (SE) factors may explain variation.
Methods:
Patients fulfilling the ASAS SpA criteria in the multi-national, cross-sectional ASAS COMOSPA study were studied. Multi-level logistic regression models with random intercept for country were constructed with current use of bDMARDs as the dependent variable. Contribution of socio-economic factors using country health expenditures and gross domestic product (GDP) (all low vs medium/high tertiles) as independent country-level factors, was explored in models adjusted for socio-demographic as well as clinical variables known to determine bDMARD-use in SpA.
Results:
In total, 3370 patients from 22 countries were included (mean [SD] age 43 [14] years; 66% male; 88% axial disease). Across countries, 1275 (38%) were bDMARD users. Crude mean bDMARD-use varied between 5% (China) to 74% (Belgium). After adjustment for relevant socio-demographic and clinical variables, important variation in bDMARD-use across countries remained (Figure, p<0.001). Country-level socio-economic factors, specifically higher health expenditures were related to higher bDMARD uptake (Table), though not meeting statistical significance (OR 1.91; 95%CI 0.93,3.92). Similar findings were found with country GDP (OR 1.72;95%CI 0.83,3.57).
Image/graph:
Conclusions:
There remains important residual variation across countries in bDMARD uptake of patients with SpA followed in specialized SpA centers. This is despite adjustment of well-known factors for bDMARD use such as clinical and country-level socio-economic factors.
