[Epidemiological and public health aspects of inflammatory rheumatic systemic diseases]

[Physical therapy options in rheumatic diseases: what is evidence-based?]

Rheumatic diseases usually progress towards morphological and functional deficits and thus cause impairment of physical health and function. Based on this fact, physiotherapeutic options are elementary and indispensable. This article focuses on the significance and importance of physiotherapy in inflammatory and degenerative rheumatic diseases. Furthermore, an overview is presented on the consequences of rheumatic diseases, the reality of supply of physiotherapy, the principles and therapeutic options, and the evidence.

[Prevalence, comorbidity and interdisciplinary treatment of rheumatoid arthritis - Insurance data on outpatient and inpatient care in Baden-Württemberg]

BACKGROUND

Rheumatoid arthritis (RA) has an increased number of comorbidities compared with the general population.

OBJECTIVE

Study aim was to collect epidemiological data on prevalence, incidence and comorbidities of RA as well as utilization of outpatient and inpatient care services.

MATERIAL AND METHODS

In an age and gender-adjusted case control study, a total of 3.4 million patients insured by the AOK Baden-Württemberg were analysed with respect to visits to physicians, prevalence, incidence and comorbidities of RA. The study was based on out- and inpatient diagnoses from 2013.

RESULTS

The RA prevalence was 0.64% (n = 26,919), the incidence was 0.04%. Patients with RA have significant more comorbidities in almost all diagnosis groups, especially in musculoskeletal and cardiovascular diseases, compared to a control group (n = 181,209). 22.8% of RA patients had not contacted an internist rheumatologist, orthopedist or orthopedic surgeon. Biological disease-modifying anti-rheumatic drugs (DMARDs) were almost exclusively prescribed by internist rheumatologists, while conventional DMARDs were equally prescribed by general practitioners and rheumatologists. Of the RA patients 32.6% were hospitalized at least once a year and were nearly twice as frequently inpatient as the control group.

CONCLUSION

RA patients need more in- and outpatient healthcare services and suffer significantly more often from comorbidities. The general practitioner is the most frequently visited physician. Other consulted physicians are rheumatologists, ophthalmologists, orthopedists/orthopedic surgeons and internists not specialized in rheumatology. The study highlights the need to create consensus treatment algorithms and maintain a close interdisciplinary and intersectoral cooperation and communication.

[Orthoses and assistive devices in rheumatology : Prevention of disability, support of residual function]

Due to the frequent presence of comorbidities in patients suffering from rheumatism with increased perioperative risk factors, conservative treatment is often needed. Besides pharmacological treatment, physiotherapy and occupational therapy, a variety of orthoses are available depending on the individual indications. They can be used to stabilize or support joints, limit the range of motion, prevent unphysiological movements or provide relief for affected limbs. In order to choose the right kind of orthosis, the physician should know the underlying cause of disease. Furthermore, for patients with rheumatism many devices are available for daily living that use ergonomic handles or improved leverage effects to compensate for the often severe limitations and to improve the quality of life.

[Evidence-based physiotherapeutic strategies for musculoskeletal pain]

Inflammatory rheumatic disorders usually progress towards morphologic and functional deficits and thus cause substantial impairment of physical health. Amongst the therapeutic options physiotherapeutic strategies are essential and are often required to maintain the individual's quality of life. Because of the large variety of physiotherapeutical approaches, differentiated clinical examination is needed in order to implement physiotherapeutics in a treatment plan that is based on pathophysiologic and regeneration-specific aspects. The article presents a current overview of evidence-based physiotherapeutic strategies for musculoskeletal pain reduction in daily practice.

[Expression analyses for rheumatoid arthritis]

Inflammatory rheumatic diseases with their unclear aetiology are a challenge for the routine clinical practice. The dominating inflammatory processes with many facets of autoimmune phenomena have been extensively studied during the last decades. Modern high throughput technologies provide for the first time the opportunity to obtain an insight into the many different molecular aspects in one patient in parallel. Step by step, concepts can be developed to understand the relationships and interdependencies of the molecular processes and to place them in order of importance for each individual separately. Thus, studies have demonstrated that the risk of disease severity can be estimated and the response to therapy can be objectified based on molecular investigations. Exemplarily, the potential has been demonstrated that the therapeutic outcome towards a defined treatment may be predicted. Despite the high cost, it is becoming more and more obvious that an extensive increase of knowledge depends on the detection of a multitude of parameters, a task which will need to be accomplished in the near future.

Strukturen der akutstationären rheumatologischen Versorgung

Severe rheumatological systemic diseases demand high levels of diagnostic and therapeutic measures and differentiated and complex methods of care. In Germany, specialised rheumatologists and, if hospitalisation is indicated, specialised rheumatology hospitals or departments are responsible for the treatment of these patients. Early rehabilitation procedures, provided by a multidisciplinary therapeutic team, are an important component of the treatment concept in these facilities. Early rehabilitation is integrated into the patients acute medical treatment plan, with careful consideration of the patients current health problems and functional capabilities (body functions and structures, activities and participation as outlined in the ICF), thereby providing a comprehensive, integrated therapy strategy which has long been acknowledged as necessary for the successful treatment of rheumatoid patients. This article presents an analysis concerning the development, organisation, facilities and processes of the acute medical in-patient care for patients with rheumatological disorders in Germany. In total there are 4188 beds in 88 acute hospitals exclusively available for rheumatological in-patients in Germany at present. There is at least one facility specialised in rheumatology in every German federal state. The density of care in the German federal states varies between 131.8 beds per 1 million inhabitants in Bremen and 9 beds per 1 million inhabitants in Saxony. In most regions of Germany the acute in-patient care for patients with rheumatological disorders is provided by hospitals specialised in rheumatology. Rheumatological patients are treated in a variety of hospital departments. In the year 2000 only 47% of the inpatients with rheumatoid arthritis, 56% of those with ankylosing spondylitis and 28% of those with systemic lupus erythematosus were treated in a ward specialising in rheumatology. Rheumatoid arthritis, with a total share of nearly 30%, was the most frequently treated rheumatic disease in wards specialising in rheumatology, followed by soft tissue disorders (e.g. fibromyalgia), diseases with systemic involvement of connective tissue and inflammatory spinal disorders such as ankylosing spondylitis.

Prevalence and correlates of inflammatory arthritis in Germany: data from the First National Health Survey

The aim of this paper is to generate data on the prevalence of inflammatory arthritis in different subgroups of the population and to identify correlates on the basis of population-based cross-sectional data: the "First National Health Survey of the Federal Republic of Germany". This Survey investigated the prevalence of inflammatory arthritis, comorbidity and health-relevant behaviors on the basis of interviews with physicians and medical evaluations conducted in the period from October 1997 to March 1999. The study was based on a net sample comprising 6,461 subjects aged 18-79. Our data demonstrate an overall prevalence of 3.4% for inflammatory arthritis. The prevalence of inflammatory arthritis is significantly higher in women, the over-50, lower-income groups, and habitual smokers. Patients with inflammatory arthritis have a higher rate of numerous comorbidities such as osteoporosis, thyroid disease, chronic bronchial disease, hypertension, and elevated blood lipids versus healthy reference groups.

[Health economic research in rheumatic diseases]

Thorough health economic research of budget-relevant diseases should be one of the major tasks in the German health care system. Up to now cost studies were only performed for special research questions and/or with very limited focuses, e.g. the patients' view. Hence, federal programmes, like competence networks for certain diseases, which were introduced by the German Ministry for Research and Education in the late 1990s, should give a broader focus on health services research. With such an approach health politicians may obtain a deeper insight into areas of the health care sector which are likely to be more efficient after reorganisation. The process of a structured analysis of certain diseases will be demonstrated using the example of rheumatoid arthritis (RA). To this end, the results of a research programme sponsored within the Competence Network for Musculoskeletal Diseases will be presented. Direct costs, indirect costs as well as values for health-related quality of life of German RA patients in routine care by generalists and specialists will be discussed.

Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide in rheumatoid arthritis in Germany: I. Selected DMARDs and patient-related costs

OBJECTIVE

To quantify direct costs of medication and cost of illness (according to functional capacity) for patients with rheumatoid arthritis (RA) in Germany, allowing further use in a health economic evaluation of sequential therapy with disease-modifying antirheumatic drugs (DMARDs) in specialised, i.e. rheumatological, care in Germany.

DESIGN AND SETTING

The analysis was conducted from the societal perspective in Germany using a modelling approach, which was based on secondary analysis of existing data and on data from a sample of 583 patients from the German rheumatological database of 1998. Functional capacity was defined by the Hannover Functional Ability Questionnaire (HFAQ) scores. Costs were calculated from resources utilised and patients' work capacity. Direct costs consisted of outpatient medical services, inpatient treatment, long-term care and rehabilitation treatment. Indirect costs incurred by sick leave and premature retirement were quantified according to the human-capital approach.

MAIN OUTCOME MEASURES AND RESULTS

Average total direct costs (year 1998-2001 values) per patient per year for continuous treatment with the selected DMARDs comprising costs for drugs, monitoring and treatment of adverse drug reactions (ADRs) were highest for intramuscular gold (sodium aurothiomalate) [euro 2106 (euro 1 approximately equal to $US 0.91; average of the period from 2000 through 2001)] followed by leflunomide (euro 2010), azathioprine (euro 1878), sulfasalazine (euro 1190), oral methotrexate (euro 708), and lowest for the antimalarials chloroquine/hydroxychloroquine (euro 684). There were additional yearly costs for RA-related non-DMARD medication of euro 554 per patient, including management of ADRs. Mean cost of illness (year 1998 values) excluding medication cost amounted to euro 17,868 per RA patient per year. Annual costs increased with increasing disability, i.e. decreasing functional capacity, of RA patients from euro 6029 per patient with more than 94% of functional capacity to euro 28,509 per patient with <20% of functional capacity. In general, there was a predominance of indirect costs in each of the categories of functional capacity, ranging between 74% and 87% of total (direct and indirect) annual costs per RA patient. Annual direct costs increased from euro 811 to euro 7438 per patient with increasing disability. Inpatient treatment was the predominant component of direct costs. Patients in the worst category (<20%) of function experienced hospital costs that were 6.5 times higher than those of patients in the best category (>94%).

CONCLUSIONS

On the basis of the data presented it can be concluded that the results of this investigation are typical for patients in rheumatological care in Germany and can therefore be used in a health economic analysis of different DMARD sequences aimed at changing disease progression over time.

Burden and cost of illness in patients with juvenile idiopathic arthritis

OBJECTIVE

To estimate the cost of illness in an incidence based cohort of patients with juvenile idiopathic arthritis.

METHODS

Direct costs (healthcare and non-healthcare costs) and indirect costs (productivity loss due to sick leave and work disability) were measured in 215 JIA patients, assessed on an average of 17 years after disease onset. Assessment included a clinical evaluation, a structured interview, and two self completion questionnaires. Annual direct costs were estimated based on the reported use of healthcare services and resources, using average unit prices. Indirect costs were estimated from the number of work days missed-that is, using the human capital approach.

RESULTS

The mean total cost of late JIA was estimated to be 3500 per patient and year, of which the direct cost contributed more than half. Patients with still active disease (55%) incurred the major share (90%) of the cost. They had a mean total cost of 5700 per patient year, with those under rheumatological care incurring a cost of 9300. Having a certain JIA subgroup, functional disability, or receipt of specialised care independently contributed to the total cost in active JIA. Highest mean total costs were found in active seropositive polyarthritis (17 000) and extended oligoarthritis (11 000), while the lowest were found in active enthesitis related arthritis (1500) and persistent oligoarthritis (2700).

CONCLUSIONS

Estimated 12 month costs in late JIA are considerable, differing among the various JIA subgroups. Treatment strategies in JIA should be analysed for their cost effectiveness in the long term.

[Internist's therapy of rheumatoid arthritis]

Rheumatoid arthritis is the most common inflammatory joint disease and is characterized by chronic, symmetric, erosive synovitis of small joints of hands and feet. Prevalence in women is threefold higher than in man. Structural damage of the joints starts between the first and second year of the disease. Early therapeutic interventions can alter the course of rheumatoid arthritis by delaying the progression of radiographic joint destruction, which correlates with the grade of disability. Approval of new biologic antirheumatic drugs in the last few years improved the outcome of rheumatoid arthritis.

Effect of Wegener's granulomatosis on work disability, need for medical care, and quality of life in patients younger than 40 years at diagnosis

OBJECTIVES

To evaluate the effects of Wegener's granulomatosis (WG) on employment status, work disability, and need for medical care of 60 consecutive WG patients aged < or = 40 years at diagnosis.

METHODS

Sixty WG patients (26 male, 34 female) with a median age of 36 years (range 17-48 years) and a median duration of disease of 39 months (range 0-228 months) completed self-administered questionnaires on hospitalization, medical care, and employment status plus the Medical Outcomes Study-Short Form-36 (SF-36) estimating their health-related quality of life.

RESULTS

Thirty-two of the 60 patients reported full- or part-time employment more than 3 years after diagnosis. Only 14 of the 51 patients employed at diagnosis (27%) were currently receiving a permanent work disability pension due to WG. Two additional patients had lost work because of WG. Women who were employed at diagnosis had a nearly 3-fold higher risk of losing their jobs compared with men (P = 0.0006). There were no differences with regard to age at diagnosis, disease duration, disease severity, or education level between employed and unemployed patients. Employed patients had missed a median of 14 workdays (range 0-18 days) due to WG within the past 12 months. More than half of all patients (33 of 60) had been hospitalized during the previous 12 months because of WG. Ninety-three percent of all patients had visited their physician once or more per month, more than half of them at least once per week, regardless of employment status, severity of disease, or type of current medication. Unemployed WG patients experienced significant reductions in social and physical function and in their perceived degree of general health as assessed by the SF-36.

CONCLUSIONS

Twenty-seven percent of WG patients younger than age 40 who were employed at diagnosis received permanent work disability within a disease duration of 39 months. Unemployment is followed by a considerable reduction in disease-related quality of life compared with employed patients, independent of severity and extent of disease. Furthermore, because patients were followed closely by an interdisciplinary team, a high rate of hospitalization and frequent visits to physicians resulted.