In patients with RA, important differences in physician-reported and patient-reported outcomes across countries were seen, with overall a paradox of worse physician-reported outcomes but better patient-reported outcomes in low-income countries, while results indicate that these outcomes in multinational studies should be interpreted with caution. Research on explanatory factors of this paradox should include non-disease driven cultural factors influencing health.

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

Country of residence has an important influence on fatigue. Paradoxically, patients from wealthier countries had higher fatigue.

In addition to drug efficacy, rheumatologists account for economic aspects and for patients' preferences when deciding on drugs. Decisions are more influenced by absolute costs than relative cost-effectiveness and by patients' disliking as opposed to favouring the treatment.

ObjectiveAs part of European League against Rheumatism (EULAR)/European Musculoskeletal Conditions Surveillance and Information Network, 20 user-focused standards of care (SoCs) for rheumatoid arthritis (RA) addressing 16 domains of care were developed. This study aimed to explore gaps in implementation of these SoCs across Europe.MethodsTwo cross-sectional surveys on the importance, level of and barriers (patients only) to implementation of each SoC (0–10, 10 highest) were designed to be conducted among patients and rheumatologists in 50 European countries. Care gaps were calculated as the difference between the actual and maximum possible score for implementation (ie, 10) multiplied by the care importance score, resulting in care gaps (0–100, maximal gap). Factors associated with the problematic care gaps (ie, gap≥30 and importance≥6 and implementation<6) and strong barriers (≥6) were further analysed in multilevel logistic regression models.ResultsOverall, 26 and 31 countries provided data from 1873 patients and 1131 rheumatologists, respectively. 19 out of 20 SoCs were problematic from the perspectives of more than 20% of patients, while this was true for only 10 SoCs for rheumatologists. Rheumatologists in countries with lower gross domestic product and non-European Union countries were more likely to report problematic gaps in 15 of 20 SoCs, while virtually no differences were observed among patients. Lack of relevance of some SoCs (71%) and limited time of professionals (66%) were the most frequent implementation barriers identified by patients.ConclusionsMany problematic gaps were reported across several essential aspects of RA care. More efforts need to be devoted to implementation of EULAR SoCs.

Background For patients with rheumatoid arthritis (RA), fatigue is an important aspect of disease which impacts quality of life. However the complex relationship between fatigue and either disease-related or external factors remains unclear. Country of residence as a surrogate for a variety of cultural, economic, climatological and linguistic aspects might play a role, but this has never been formally explored. Objectives To investigate how country of residence influences level of fatigue in addition to socio-demographic and objective disease- characteristics. Methods Data from a multi-national study were used (COMORA). Fatigue was measured using 0-10 VAS scale. A multivariable linear regression model (outcome fatigue) was computed using manual forward selection. Contribution of socio-demographic factors (age, gender, education, marital status, work status), comorbidities (Wolfe-Michaud index), smoking status, clinical disease characteristics (tender and swollen joints (TJC, SJC), erosions in hands or feet (yes/no), erythrocyte sedimentation rate) and medication (all type of DMARDs, steroids and NSAIDs) was tested. Country of residence was added using the country with the highest level of fatigue (Netherlands) as reference. In a second step, sensitivity analyses were developed replacing country of residence by country specific variables including gross domestic product (GPD), human development index (HDI), a climate indicator (latitude) and income inequality (gini index). Results 3920 patients from 17 countries (range: 30 to 411, mean age 56 years (SD 13), 82% female). Mean fatigue across countries was 4.13 (SD 2.8). 32.8% of all patients had fatigue scores >5. In multi-variable regression, female gender (βf=1=0.72, CI 0.50/0.93) and a higher comorbidity score (β=0.30, CI 0.24/0.37) were associated with higher fatigue. TJC and SJC had limited influence on fatigue with higher contribution of TJC (βTJC=0.14, CI 0.12/0.16 and βSJC=0.05, CI 0.25/0.79). When adding country, the contribution was significant and increased the overall model fit (Δ R2=0.07). Country differences in fatigue varied between -3.9 for Venezuela vs Netherlands (NL) and -0.6 (Italy vs NL) after adjustment for individual factors. When country was replaced by GDP, HDI, latitude or gini index, only GPD and HDI index contributed significantly. The overall model improvement was lower compared to country (R2 GDP=0.14, R2 HDI=0.18, R2 country=0.20). Interactions were not significant. Conclusions While individual demographics and objective clinical measures of disease have only a small influence on the experience of fatigue, the country of residence adds substantially. Economic and development status of the country only explain small parts of the variation among countries. More research is needed to identify other relevant cultural (attitudes, believes), climatological or linguistic aspects that could explaining fatigue. Disclosure of Interest M. Hifinger Employee of: Hexal AG, Germany (inactive employment, maternity leave), P. Putrik: None de...

ObjectiveTo assess the influence of disease activity of patients with rheumatoid arthritis on treatment choices of rheumatologists in countries with restricted access to expensive, innovative drugs.MethodsRheumatologists from Hungary, Romania and UK were invited to complete two consecutive discrete choice experiments with hypothetical drug treatments for two different patient profiles: high and moderate disease activity. Rheumatologists were asked to choose repeatedly between two unlabelled treatment options that differed in five attributes: efficacy (expected improvement and achieved disease activity state), safety (probability of serious adverse events), patient's preference (level of agreement), total medication costs and cost-effectiveness. A heteroscedastic discrete choice model using interaction terms between attribute levels and patient profiles (binary variable) was used to assess the preferences of rheumatologists towards each attribute and the influence of the patient profile.ResultsOverall, 148 rheumatologists completed the survey (46% females, mean age 49 years, 49% academic). For both patient profiles, efficacy dominated the treatment choice over patient's preference, safety and economic aspects. However, for patients with high compared with moderate disease activity, the importance of drug efficacy significantly increased (from 48% for moderate to 57% for high disease activity), whereas the importance of patient's preference significantly decreased (from 15% to 11%). No significant differences were observed for economic and safety considerations.ConclusionRheumatologists were willing to give up some efficacy to account for patient's preference when choosing treatments for patients with moderate compared to high disease activity. Disease activity however did not influence importance of economic aspects in treatment choices.

BackgroundEconomic considerations and patient preferences are increasingly important when choosing treatments. It is not known to what extent rheumatologists across Europe account for these factors when changing drug therapies in patients with active rheumatoid arthritis (RA).ObjectivesTo evaluate the extent to which rheumatologists across Europe consider costs, cost-effectiveness and patient preferences in addition to efficacy and safety in treatment decisions in RA.MethodsIn a discrete choice experiment, rheumatologists were asked to choose iteratively between two unlabelled drug treatment options for a hypothetical RA patient with moderate disease activity who failed two synthetic DMARDs. The treatment options were characterized by five attributes further specified by three levels; efficacy (level of improvement and achieved state on DAS28), safety (probability of a serious adverse event), patient preference (level of agreement with proposed treatment), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). Attributes and levels were selected based on literature data and expert consensus. An efficient experimental design was used to construct 14 treatment choices and a mixed logit model was used to estimate the relative importance of attributes.Results452 rheumatologists from 11 European countries contributed to the analysis (51% females, mean age 49 years). In all countries, drug-efficacy had the strongest influence on the rheumatologists' preferred drug choice. In addition, patient preferences were taken into account, especially when patients did not favour the drug. With regard to economic attributes of the drug, medication costs influenced the treatment choice more than ICER (table 1). However relative importance of ICER differed across countries (2-13%).ConclusionsThis study suggests that efficacy had the highest impact on treatment decisions. But for rheumatologists also patient preferences were relevant. Among the economic considerations, overall medication costs primarily influenced treatment decisions in RA, while ICER played a more limited role, especially in some countries.Disclosure of InterestM. Hifinger Employee of: Hexal AG, Holzkirchen, Germany (maternity leave), M. Hiligsmann: None declared, S. Ramiro: None declared, H. Severens: None declared, B. Fautrel: None declared, V. Watson: None declared, T. Uhlig: None declared, R. van Vollenhoven: None declared, P. Jacques: None declared, J. Detert: None declared, C. Scirè: None declared, J. Canas da Silva: None declared, F. Berghea: None declared, L. Carmona: None declared, M. Péntek: None declared, A. Boonen: None declared