title: Less educated and older patients have reduced access to biologic DMARDs even in a country with highly developed social welfare (Norway): results from Norwegian cohort study NOR-DMARD.
abstract: To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA.
  
  
  
  Data from the Norwegian Register of DMARDs collected between 2000 and 2012 were used. Only DMARD-naïve patients with RA starting their first conventional synthetic DMARD were included in the analyses. The start of the first bDMARD was the main outcome of interest. Cox regression analyses were used to explore the impact of education, age and gender on the start of a first bDMARD, adjusting for confounders, either at baseline or varying over time (time-varying model).
  
  
  
  Of 1946 eligible patients [mean (s.d.) age: 55 (14) years, 68% females], 368 (19%) received a bDMARD during follow-up (mean 2.6 years). In the baseline prediction model, older age [Hazard Ratio (HR) 0.97, 95% CI: 0.96, 0.98], lower education [HR = 0.76 and 0.68 for low and intermediate education levels vs college/university education, respectively (P = 0.01)] and female gender [only in the period 2000-03, HR = 0.61 (95% CI: 0.41, 0.91)] were associated with a lower hazard ratio to start a bDMARD. The time-varying model provided overall consistent results, but the effect of education was only relevant for older patients (>57 years) and became more pronounced by the end of the decade.
  
  
  
  Less educated and older patients have disadvantages with regard to access to costly treatments, even in a country with highly developed welfare like Norway. Females had lower access in the beginning of the 2000s, but access had improved by the end of the decade.
authors.affiliation: Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University Health Promotion and Education, Maastricht University, Maastricht polina.putrik@gmail.com.
authors.forename: Polina
authors.initials: P
authors.lastname: Putrik
authors.affiliation: Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Sofia
authors.initials: S
authors.lastname: Ramiro
authors.affiliation: Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Lie
authors.affiliation: Medical Informatics, Uniklinik RWTH Aachen University, Aachen, Germany.
authors.forename: Andras P
authors.initials: AP
authors.lastname: Keszei
authors.affiliation: Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Tore K
authors.initials: TK
authors.lastname: Kvien
authors.affiliation: Rheumatology, Leiden University Medical Center, Leiden, the Netherlands Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Désirée
authors.initials: D
authors.lastname: van der Heijde
authors.affiliation: Amsterdam Rheumatology & Immunology Center, Amsterdam, Amsterdam Rheumatology, Atrium Medical Center, Heerlen, the Netherlands and.
authors.forename: Robert
authors.initials: R
authors.lastname: Landewé
authors.affiliation: Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University Rheumatology, Diakonhjemmet Hospital, National Advisory Unit on Rehabilitation in Rheumatology, Oslo, Norway.
authors.forename: Till
authors.initials: T
authors.lastname: Uhlig
authors.affiliation: Rheumatology, Maastricht University Medical Center and CAPHRI Research Institute Maastricht University.
authors.forename: Annelies
authors.initials: A
authors.lastname: Boonen
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D015331:Cohort Studies; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009664:Norway; D016016:Proportional Hazards Models; D012042:Registries; D012737:Sex Factors; D012946:Social Welfare / Q000706:statistics & numerical data*
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products
keywords: attitude of health professionals; biological therapies; epidemiology; health policies; rheumatic diseases