A new study published in the Annals of the Rheumatic Diseases highlighted substantial disparities across European countries in terms of access to rheumatologists, treatments, and nonpharmacologic care for rheumatic and musculoskeletal diseases (RMDs). The study analyzed data from 36 member countries of the European Alliance of Associations for Rheumatology (EULAR). The primary objective was to establish a longitudinal baseline for monitoring inequalities and assessing progress toward more equitable care.

RMDs are among the leading causes of disability worldwide and account for about 1 in 5 years of life with disability in Europe. However, healthcare responses have historically been uneven, partly because standardized measures for comparing rheumatology resources are lacking. The first edition of the EULAR RheumaFacts project addressed this gap by providing a detailed overview of rheumatology resources and access to care across Europe.

RheumaFacts is the first harmonized database to systematically compare healthcare resources, workforce capacity, and access to rheumatology care across European countries. In this first edition, 36 of EULAR’s 40 member countries provided data through a standardized questionnaire, supplemented by demographic and economic indicators from the UN, World Bank, and World Health Organization.

Specialist Gaps

The density of rheumatologists varied substantially across the different countries from 0.8 per 100,000 adults in Ukraine to 6.6 per 100,000 in Georgia, with a median of 2.9 per 100,000. However, national income alone does not explain these differences. Germany, a high-income country, reported fewer rheumatologists per capita than Georgia or Albania, both of which are middle-income countries.

Access to specialists also varies. In half of the countries evaluated, patients could not directly see a rheumatologist in the public healthcare system without referral from a primary care physician.

The study also found substantial variation in the proportion of female rheumatologists, ranging from 33% in Austria to 93% in Armenia. Women accounted for 100% of rheumatology professorships in six countries: Albania, Armenia, Estonia, Lithuania, Moldova, and Slovenia. Lebanon reported having no women in professorship positions.

Pediatric rheumatology resources also differed according to the national income. The density of specialists treating children with rheumatic diseases was 1.40 per 100,000 children in high-income countries compared with 0.55 per 100,000 in middle-income countries.

Although international guidelines emphasize multidisciplinary care, access to long-term nonpharmacologic treatment remains limited. Publicly funded ongoing physical therapy was available in 72% of European countries and concentrated mainly in high-income settings.

Access to psychological support for persistent pain is even more limited. Only 39% of the countries provided long-term reimbursement for specialized psychological care, with no clear association between coverage and national income. In addition, only 14% of the countries had an official certification program for rheumatology nursing.

Treatment Access

Only half of the countries allow patients to see a rheumatologist without prior referral. Direct access is more common in middle-income countries than in high-income countries (89% vs 37%).

Access to nonpharmacologic care remains uneven across Europe. Physical therapy vs psychological support is routinely reimbursed in 72% vs 39% of countries, with no significant difference by income level. No country offers certified rheumatology training specifically for psychologists, whereas only Germany, Hungary, and Netherlands offer certification for occupational therapists. These gaps, combined with the limited capacity to train new specialists, could further widen disparities in care.

Access to pharmacologic treatments also varied. Although 97% of countries had access to all conventional synthetic disease-modifying antirheumatic drugs and every country had access to at least one biologic, only 34% had access to all 20 biologics evaluated. Similarly, only 51% of patients had access to a full range of targeted synthetic drugs, including JAK inhibitors.

The authors noted that regulatory approval or availability does not necessarily mean that the treatment is reimbursed or affordable for patients. Therefore, the reported figures represent only the first layer of the access problem.

Speaking with Univadis Spain, part of the Medscape Professional Network, Loreto Carmona, MD, PhD, a rheumatologist and research director at the Instituto de Salud Musculoesquelética in Madrid, Spain, said that, “Let’s be fair: Medications have radically changed the landscape of [RMDs]. The advent of biologic disease-modifying drugs and, more recently, targeted synthetic drugs has transformed diseases that once condemned patients to deformity and dependence into manageable conditions, with sustained remission in many cases. That achievement is real and should not be downplayed. Therefore, the problem is not that these drugs are not funded. The problem is that they are funded instead of and not alongside comprehensive care. The data from the RheumaFacts project by the [EULAR] speak for themselves: All European countries report access to at least one biologic, but chronic physical therapy is reimbursed in only 72% of countries and psychological support in just 39%.

“The reason has to do with incentives, not evidence. A drug has a visible price, a clinical trial, and a manufacturer that advocates for it before funding committees. Physical therapy and psychology produce diffuse, long-term benefits that do not align well with 4-year election cycles. The system has evolved such that a crisis triggers the allocation of resources: Hospitalization due to a severe flare-up immediately mobilizes resources; psychology sessions, therapeutic exercise, or nursing support, which could have prevented it, do not. Drugs have won a battle against inflammation. Now, we need healthcare systems to win the battle against chronic disease. And that cannot be achieved with molecules alone,” she said.

Innovation and Access

Carmona also highlighted the gap between advances in treatment and access to these treatments.

“Innovation alone is not enough to benefit patients or the system. As a rheumatologist and epidemiologist and having participated in the first edition of the EULAR RheumaFacts project, I fully understand the frustration underlying this question. It is a painful paradox: We are living in a golden age of innovation in treatments for [RMDs], but the reality is that a patient’s zip code continues to determine their prognosis and quality of life. Moreover, the data we collected across 36 European countries show that these inequities are not anecdotal but rather structural and profound.

“It is true that all EU countries reported having access to at least one biologic disease-modifying antirheumatic drug. However, medical innovation is not based on having ‘at least 1,’ but rather on having the appropriate therapeutic arsenal for each patient. Our study revealed that only 12 of the 36 countries (34%) have access to all biologic disease-modifying antirheumatic drugs, and only 51% have access to all targeted synthetic drugs. This means that for many European patients, if first- or second-line treatment fails, innovative options are simply not available in their healthcare systems.

“Access to innovation depends not only on whether the drug is covered but also on whether a specialist is available to prescribe it in a timely manner. We documented substantial variation in the density of rheumatologists, ranging from 0.8 [to] 6.6 per 100,000 inhabitants, with a median of 2.9.

“In countries with lower density, diagnostic delays are inevitable, and for diseases such as rheumatoid arthritis or spondyloarthritis, time means loss of cartilage and bone. An innovative drug loses much of its effectiveness if it is administered only after joint damage has already become irreversible.

“Furthermore, innovation is not limited to [pharmacologic] treatments. The management of [RMDs] requires a multidisciplinary approach. However, our study showed that long-term physical therapy is reimbursed in only 72% of countries, and psychological support, which is crucial for patients with chronic pain, is reimbursed in just 39%. There is no point in prescribing the most advanced medication if physical and mental rehabilitation are neglected.

“What, then, is the point of scientific progress? It matters because it defines the boundaries of what is possible. However, as an epidemiologist, it is my duty to warn that science without equity is not public health but a privilege.

“The RheumaFacts project was not created simply to lament these figures but to provide the empirical evidence needed for policy action. European and national policymakers can no longer hide the lack of data. We now know exactly where these gaps lie. Our demand from the [EULAR] is clear: Investment in health must address both the development of new drugs and the strengthening of healthcare systems so that these drugs reach those who need them. Medical innovation only fulfills its ethical and social purpose when it is accessible to all patients, regardless of the country in which they reside,” she said.

Next Steps

RheumaFacts is designed as a longitudinal tool that is updated periodically to monitor how inequalities change over time. The team also plans to cross-reference these data with the EULAR Survey on the Impact of Rheumatic Diseases to examine how healthcare system characteristics affect the burden experienced by patients. Future analyses will also include other healthcare professionals who care for patients with RMDs, including specialized nurses.

The authors of the study and Carmona reported having no relevant financial conflicts of interest.

This story was translated from Univadis Spain, part of the Medscape Professional Network.