E x t e n d e d r e p o r t Table 4 GDP and treatment-related variables in the QUEST–RA study in Europe and other countries, in descending order of GDP GDP 2005 per capita US$1000 Patients taking DMARD ever, % Delay to start DMARD, months, median No of Methotrexate DMARD ever, % of ever taken patients Prednisone ever, % of patients Biologicals ever, % of patients Any DMARD, % of disease duration Methotrexate, % of disease duration 1670 Ann Rheum Dis 2009;68:1666–1672. doi:10.1136/ard.2009.109983 55.7 65.6 73.7 87.6 109.6 51.3 77.0 66.5 66.9 67.4 104.2 54.3 67.4 64.0 45.3 52.9 64.6 82.4 83.8 77.6 70.2 64.0 75.3 115.7 46.3 71.6 p Value{ ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 28.9 25.5 31.1 45.0 25.7 24.6 31.0 28.8 28.9 30.9 50.8 20.1 23.8 26.3 21.2 28.0 25.2 36.8 39.5 22.1 31.3 28.6 33.4 57.6 24.5 30.8 Biologicals, % of disease duration 6.6 2.9 7.2 4.4 2.2 1.9 8.9 6.3 2.9 4.4 14.6 0.7 0.3 0.9 1.7 1.6 0.3 0.2 8.5 5.0 1.9 9.7 0.7 3.7 0.5 3.9 Country Europe Ireland Denmark Sweden The Netherlands Finland UK France Germany Italy Spain Greece Hungary Estonia Poland Lithuania Latvia Serbia Kosovo Non-Europe USA Canada UAE Russia Turkey Brazil Argentina Total 48.7 47.9 39.6 38.9 37.3 37.3 35.0 33.9 30.5 26.1 25.6 10.9 10.3 8.0 7.5 7.0 3.5 3.5 41.9 35.2 32.4 5.3 5 4.8 4.7 98.0 99.0 94.0 99.0 100.0 95.0 99.0 92.0 96.0 98.0 100.0 96.0 98.0 99.0 96.0 98.0 96.0 100.0 98 95 88 88 99 100 88 97 10.0 10.0 12.0 5.0 7.0 12.0 8.0 15.0 9.0 13.0 7.0 12.0 12.0 4.0 13.0 24.0 11.0 3.0 9.0 11.0 11.0 10.0 12.0 8.0 13.0 9 2.4 2.8 2.8 2.3 4.0 2.4 3.7 2.7 2.4 2.8 2.9 2.6 2.8 3.0 2.3 2.2 2.0 2.0 2.1 3.0 1.8 1.8 2.4 3.0 1.5 2.7 DMARD, disease-modifying antirheumatic drug; GDP, gross domestic product; UAE, United Arab Emirates. duration in ‘‘high GDP’’ and ‘‘low GDP’’ countries. Disease activity levels appeared much more associated with the wealth of the country than current medications (table 5). The current use of biological agents appeared to have a greater inverse association with disease activity in ‘‘low GDP’’ than in ‘‘high GDP’’ countries (table 5). GDP explained 61% of the variation in DAS28 scores, consistent with extensive observations of differences in health status and mortality in different nations according to a nation’s wealth.7–9 Differences in DAS28 scores according to GDP are at least twice as great as improvements in DAS28 achieved in any clinical trial of the most powerful biological agents. The data echo a suggestion made by Virchow in 1848 that ‘‘the improvement of medicine would eventually prolong human life, but improvement of social conditions could achieve this result now more rapidly and more successfully.’’25 Many psychological constructs, including stress, anxiety, depression, limited social support, learned helplessness and lack of optimism, are prognostic of higher mortality rates in individuals.23 26–28 These reports suggest that associations of low Table 5 Disease activity in ‘‘high GDP’’ and ‘‘low GDP’’ countries, according to current medications ‘‘High GDP’’ countries ‘‘Low GDP’’ countries DAS28, mean DAS28, mean Methotrexate Taking methotrexate now No methotrexate now p Value* Prednisone Taking prednisone now No prednisone now p Value* Biologicals Taking biologicals now No biologicals now p Value* *Comparison within ‘‘high GDP’’/‘‘low GDP’’ countries. {Comparison between ‘‘high GDP’’/‘‘low GDP’’ countries. DAS28, disease activity score in 28 joints; GDP, gross domestic product. 93 86 84 92 86 83 87 80 81 87 94 85 83 89 84 92 69 82 85 76 73 73 89 98 68 85 3.6 3.8 0.003 3.9 3.5 0.001 3.7 3.7 0.63 71 44 69 30 74 54 83 54 72 68 94 58 76 80 97 79 88 95 77 62 56 41 75 81 83 71 42 23 33 23 17 20 53 29 27 27 54 16 1 10 11 23 2 1 33 28 10 18 7 27 3 23 5.1 5.2 0.028 5.3 4.8 0.001 4.4 5.2 ,0.001