Objective To evaluate temporal and regional variation in biologic and targeted synthetic DMARD (b/tsDMARD) initiation for rheumatoid arthritis (RA) in England and Wales. Methods An observational cohort study was conducted for people with RA enrolled in the National Early Inflammatory Arthritis Audit (NEIAA) between May 2018 and April 2022 who had 12-month follow-up data. Temporal trends in escalation to b/tsDMARDs within 12 months of initial rheumatology assessment were explored, including comparisons before and after publication (July 2021) of national guidelines that lowered the threshold for b/tsDMARD initiation to include moderate-severity RA. Case-mix-adjusted, mixed-effects regression was used to evaluate regional and hospital-level variation in b/tsDMARD initiation. Results Of 6,098 RA patients with available follow-up, 508 (8.3%) initiated b/tsDMARDs within 12 months of initial assessment. b/tsDMARD escalation increased marginally towards the end of the study period (9.2% in May 2021/22); however, no significant differences were evident after guidelines were published permitting b/tsDMARDs for moderate-severity RA. The proportion of individuals escalated to b/tsDMARDs varied considerably between regions, ranging from 5.1% in Wales to 10.7% in North-West England. Following case-mix adjustment, the intraclass correlation (ICC) for hospitals within regions was 0.17, compared with a between-region ICC of 0.0, suggesting that the observable regional variation reflected hospital-level differences rather than systematic differences between regions themselves. Conclusion There is marked variation in escalation to b/tsDMARDs for people newly-diagnosed with RA throughout England and Wales, despite a universal healthcare system. These disparities must be addressed if we are to deliver equitable access to b/tsDMARDs, regardless of geography.

中文翻译：

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使用生物和靶向合成 DMARD 治疗类风湿性关节炎的时间和区域差异：一项全国性队列研究


目的 评估英格兰和威尔士类风湿关节炎 （RA） 的生物和靶向合成 DMARD （b/tsDMARD） 启动的时间和区域差异。方法 对 2018 年 5 月至 2022 年 4 月期间参加全国早期炎症性关节炎审计 （NEIAA） 的 RA 患者进行了一项观察性队列研究，这些患者有 12 个月的随访数据。探讨了初始风湿病学评估后 12 个月内升级为 b/tsDMARD 的时间趋势，包括发布前后（2021 年 7 月）国家指南的比较，这些指南降低了 b/tsDMARD 开始的门槛，包括中度 RA。病例混合调整的混合效应回归用于评估 b/tsDMARD 启动的区域和医院水平差异。结果 在 6,098 例可随访的 RA 患者中，508 例 （8.3%） 在初步评估后 12 个月内开始使用 b/tsDMARDs。b/tsDMARD 升级在研究期结束时略有增加（2021/22 年 5 月为 9.2%）;然而，在发布允许 b/tsDMARD 用于中度重度 RA 的指南后，没有明显的显著差异。升级为 b/tsDMARD 的个体比例因地区而异，从威尔士的 5.1% 到英格兰西北部的 10.7% 不等。病例组合调整后，区域内医院的类别内相关性 （ICC） 为 0.17，而区域间 ICC 为 0.0，这表明可观察到的区域差异反映了医院级别的差异，而不是区域本身的系统性差异。结论 尽管有全民医疗保健系统，但整个英格兰和威尔士新诊断的 RA 患者升级到 b/tsDMARD 的情况存在显着差异。 如果我们要提供公平的 b/tsDMARD 访问，无论地理位置如何，都必须解决这些差异。