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

Rheumatology (Oxford). 2016 Jul;55(7):1217-24. doi: 10.1093/rheumatology/kew048. Epub 2016 Mar 24.


Objective: To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA.

Methods: 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).

Results: 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.

Conclusions: 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.

Keywords: attitude of health professionals; biological therapies; epidemiology; health policies; rheumatic diseases.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Rheumatoid / drug therapy*
  • Biological Products / therapeutic use*
  • Cohort Studies
  • Educational Status
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Male
  • Middle Aged
  • Norway
  • Proportional Hazards Models
  • Registries
  • Sex Factors
  • Social Welfare / statistics & numerical data*


  • Antirheumatic Agents
  • Biological Products