Europe Does Better Than U.S. in Treating Spondyloarthritis, Survey Data Suggest

European nations may be winning at optimizing care for people with axial spondyloarthritis (axSpA), international survey data indicate.

In data collected from physicians and patients in the U.S. and five European countries, American patients reported a greater symptom burden on average after treatment had begun, and they agreed less often with their physicians regarding satisfaction with therapy.

U.S. patients also saw their clinicians less often than did their European counterparts, Elena Nikiphorou, MD, PhD, of King’s College London, and colleagues reported in Rheumatology.

“The reasons for these differences will be complex and multi-factorial, and may warrant future work,” Nikiphorou’s group wrote. “Better understanding why these differences exist will be key to implementing targeted improvements in treatment across both regions and minimise the risk of health inequalities.”

Among the many types of inflammatory joint diseases, axSpA is one of the more difficult to diagnose and manage. Its symptoms overlap with many other pain conditions, often leading to a “diagnostic odyssey,” with Nikiphorou and colleagues citing a recent estimate that time from symptom onset to definitive diagnosis averages around 7 years. Meanwhile, because the U.S. healthcare system is unique among developed nations in its heavy reliance on private insurance, high cost, and inequality of access, care quality may differ across borders. But whether that’s true, and if so by how much, had been largely unknown.

To address this gap, the investigators analyzed survey data collected in ongoing programs by the private firm Adelphi Real World, covering 82 U.S.-based rheumatologists and 267 in France, Italy, Germany, Spain, and Great Britain. These physicians in turn provided data on a total of 2,750 patients (656 from the U.S. and 2,094 from Europe), of whom 1,011 provided their own independent survey responses (269 U.S. and 742 European).

Data included assessments of patients’ clinical condition at original diagnosis and currently. For physicians, the survey asked them to record information for their next eight axSpA patients — detailing therapies, disease severity, and their satisfaction with the patients’ then-current outcomes — along with data from the patients’ previous records. Patients completed several questionnaires such as those underpinning the Bath Ankylosing Spondyloarthritis Disease Activity Index (BASDAI), covering basically the same ground as physician reports but with more granularity. (For example, impacts on patients’ ability to work were sought.)

Patients had been under treatment for an average 4.5 years in the U.S. and 5.4 years in the five European countries. American patients were slightly older (mean 45.6 vs 43.7) and more likely to be obese. More patients in Europe were white, and more had a history of smoking.

Although earlier studies had indicated that biologic and other targeted drugs were used more commonly in the U.S., that was not the case here. Just over 72% of patients in both regions were using these products. Some differences were seen in other drug categories, though: use of nonsteroidal anti-inflammatory drugs was less common in the U.S., while old-line anti-rheumatic agents, such as methotrexate, were more common.

No real difference was seen in symptomatic burden at diagnosis as reported by physicians, but it differed significantly at the time of the survey, with a mean of 3.3 total symptoms in the U.S. versus 2.3 in Europe (P<0.0001).

A weighted kappa analysis was used to quantify alignment of physician and patient views on treatment satisfaction, with scores ranging from 0 (no agreement) to 1 (perfect agreement). At survey data collection, the U.S. kappa score was 0.35, compared with 0.42 in Europe. An even greater disparity was seen for physician versus patient assessments of patients’ disease severity: κ=0.32 in the U.S. compared with κ=0.61 in Europe.

Hospitalization rates were the same in the two regions, but clinic visits were more frequent in Europe (mean 6.5 vs 5.2 over the past year).

Another factor to bear in mind is that U.S. patients waited longer than their European counterparts to see any kind of healthcare professional after symptom onset (mean 16.3 vs 11.8 months). Once seen, American patients were referred to a specialist faster (mean 1.3 vs 3.8 months).

Other notable results were that patients’ assessments of their health-related quality of life were a bit better in the U.S. than Europe, but BASDAI scores were higher (mean 3.0 vs 2.6), indicating worse symptoms. Also, no differences in work productivity were evident.

Nikiphorou and colleagues didn’t offer their own ideas as to how these differences arose; instead they pointed to earlier studies in which authors had suggested that healthcare access and clinician training were important influences on diagnostic delay in axSpA. However, why U.S. patients disagreed so often with their physicians’ outcomes assessments remains something of a mystery.

Limitations to the study included the small sample size and cross-sectional data collection (such that different patients “were at different points in their treatment journey,” the authors noted).