Costs in rheumatology: results and lessons learned from the ‘Hannover Costing Study’

Management of Rheumatoid Arthritis in Primary Care: A Scoping Review

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

Development and Validation of an Instrument to Measure Health-Related Out-of-Pocket Costs: The Cost for Patients Questionnaire

OBJECTIVE

The growth of healthcare spending is a major concern for insurers and governments but also for patients whose health problems may result in costs going beyond direct medical costs. To develop a comprehensive tool to measure direct and indirect costs of a health condition for patients and their families to various outpatient contexts.

METHODS

We conducted a content and face validation including results of a systematic review to identify the items related to direct and indirect costs for patients or their families and an online Delphi to determine the cost items to retain. We conducted a pilot test-retest with 18 naive participants and analyzed data calculating intraclass correlation and kappa coefficients.

RESULTS

An initial list of 34 items was established from the systematic review. Each round of the Delphi panel incorporated feedback from the previous round until a strong consensus was achieved. After 4 rounds of the Delphi to reach consensus on items to be included and wording, the questionnaire had a total of 32 cost items. For the test-retest, kappa coefficients ranged from -0.11 to 1.00 (median = 0.86), and intraclass correlation ranged from -0.02 to 0.99 (median = 0.62).

CONCLUSIONS

A rigorous process of content and face development was implemented for the Cost for Patients Questionnaire, and this study allowed to set a list of cost elements to be considered from the patient's perspective. Additional research including a test-retest with a larger sample will be part of a subsequent validation strategy.

Validated Tools to Measure Costs for Patients: A Systematic Review

BACKGROUND

Increasing healthcare expenditures is a major concern to insurers and governments, but also to patients who must pay a greater proportion of their healthcare costs. The objective of this study was to identify validated tools for measuring the costs of a health condition for patients as well as the different elements to be considered when measuring costs from the patient's perspective.

METHODS

A systematic literature review was conducted from 1984 to December 2020. The search strategy was applied to seven different databases that had been identified prior as pertinent sources. Two authors independently extracted and compiled data. In case of disagreement, arbitration by two other researchers was conducted. The methodological quality of the included articles was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

Among the 679 retrieved articles, nine met the inclusion criteria. The types of costs evaluated in these studies included direct costs for patients as well as for caregivers, indirect costs, and intangible costs. The development and validation processes used in these articles included a literature search, a discussion with the involved stakeholders, the development of an initial questionnaire, the testing of the questionnaire on a sample of patients, and a critical review. Regarding the psychometric properties of the tool, only five studies tested the reliability and validity of the instrument.

CONCLUSIONS

There are very few validated tools available to measure the different health-related costs from a patient perspective. Further research is needed to develop and validate a versatile and generalizable tool using a rigorous methodological process.

Patients with rheumatic diseases share similar patterns of healthcare resource utilization

Objectives: Healthcare service needs have changed with the use of effective treatment strategies. Using data from the modern era, we aimed to explore and compare health service-related direct costs in juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and axial spondyloarthritis (AxSpA). Methods: We linked a longitudinal, population-based clinical data set from Finland's largest non-university hospital's rheumatology clinic with an administrative database on health service-related direct costs in 2014. We compared all-cause costs and costs of comorbidities between adult patients with JIA, PsA, RA, and AxSpA (including ankylosing spondylitis). We also characterized patients with high healthcare resource utilization. Results: Cost distributions were similar between rheumatic diseases (p = 0.88). In adulthood, patients with JIA displayed a similar economic burden to much older patients with other inflammatory rheumatic diseases. A minority were high utilizers: among 119 patients with JIA, 15% utilized as much as the remaining 85%. For PsA (213 patients), RA (1086), and AxSpA (277), the high-utilization proportion was 10%. Both low and high utilizers showed rather low disease activity, but in high utilizers, the patient-reported outcomes were slightly worse, with the most distinct differences in pain levels. Of health service-related direct costs, index rheumatic diseases comprised only one-third (43.6% in JIA) and the majority were comorbidity costs. Conclusions: Patients with JIA, PsA, RA, and AxSpA share similar patterns of healthcare resource utilization, with substantial comorbidity costs and a minority being high utilizers. Innovations in meeting these patients' needs are warranted.

Paid expenditures and productivity costs associated with permanent disability pensions in patients with spinal disorders: Nationwide Finnish Register-based Study, 1990-2010

PURPOSE

The objective of this study is to present the paid expenditures and productivity costs of disability pensions (DP) due to spinal disorders (SD) in Finland during 1990-2010.

METHODS

This study is a register-based national study. All new cases aged 20-64 that were granted a DP due to SD were identified from the nationwide register maintained by the Finnish Centre of Pensions. The data included sex, age group, year of the DP decision, main cause of incapacity (diagnosis) leading to permanent DP and yearly paid expenditures for DPs. Annual productivity costs were estimated based on labour force participation rate and the employment rate adjusted gross domestic product.

RESULTS

A total of 39,107 individuals (18,072 females, 21,035 males) received DPs during the study period. SDs generated 9,372 million euros extra cost during this period due to DP (females 3.5 billion, males 5.9 billion). The total DP expenditures paid increased during the first half of 1990s but decreased during the second half of 1990s (-44.8 %). For degenerative SD cases, the DP expenditure was 5.1 billion €, disc disease 3.5 billion € and for other SDs 0.7 billion €. Males, compared to females, were expected to have a rate 1.22 times greater costs due to DPs. The estimated total annual productivity costs due to SDs have been over six times higher than expenditures paid for DPs per year. The costs of DPs are different compared to occurrence rates due to salary and early retirement age differences between genders.

CONCLUSION

Despite a significant decrease in DP-associated expenditures due to SDs after 1993, the annual expenditures have stayed on a high level in Finland.

Indirect costs in patients with coronary artery disease and mental disorders: a systematic review and meta-analysis

OBJECTIVES

The aim of the present study was to systematically review the association of comorbid mental disorders with indirect health care costs in patients with coronary artery disease (CAD).

MATERIALS AND METHODS

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included, which allowed for a comparison of indirect health care costs between CAD patients with comorbid mental disorders and CAD patients without mental disorders.

RESULTS

The literature search revealed 4962 potentially relevant studies, out of which 13 primary studies met the inclusion criteria. Depression was investigated most often (N = 10), followed by anxiety disorders (N = 3) and any mental disorder not further specified (N = 3). All studies focused on return to work as indirect cost outcome. CAD patients with depression showed diminished odds for return to work, compared to CAD patients without depression (OR = 0.37; 95% CI: 0.27-0.51). The findings for comorbid anxiety and any mental disorder were inconsistent. Indirect health care costs were exclusively assessed by a patient self-report (N = 13).

CONCLUSIONS

There is strong evidence for diminished odds of return to work in CAD patients with comorbid depression, highlighting the need for integrated CAD and depression care. With regard to other comorbid mental disorders, however, the evidence is sparse and inconclusive.

Access to biologic treatment for rheumatoid arthritis in Central and Eastern European (CEE) countries

BACKGROUND

The aim of this study was to assess and compare patients' access to biologic anti-RA drugs in selected Central and Eastern European (CEE) countries and to analyze the determinants of differences between countries.

MATERIAL/METHODS

This is a multi-country survey study, based on a combination of desk research and direct contact with national RA stakeholders. Data was collected using a pre-defined questionnaire. Affordability was measured using an affordability index, calculated comparing the index of health care expenditures to the price index, using Poland as an index of 1.

RESULTS

The percentage of patients on biologic treatment in 2009 was highest in Hungary (5% RA patients on biologic treatment), followed by Slovenia (4.5%), Slovakia (3.5%), Czech Republic (2.92%), Romania (2.2%), Estonia (1.8%), and Croatia, Serbia, Poland (below 1.5%). Infliximab, etanercept, adalimumab and rituximab were included in the reimbursement system in all countries, but abatacept and tocilizumab were included only in Slovakia. In Slovenia, public payer covered 75% of the price, and 25% is covered by supplementary health insurance; in Bulgaria public payer covered 50% of etanercept and adalimumab costs, and 75% of rituximab cost. In other countries, biologic drugs are reimbursed at 100%. Affordability index for biologic drugs was the lowest in Slovenia (0.4). In each country national guidelines define which patients are eligible for biologic treatment. Disease Activity Score (DAS28) of over 5.1 and failure of 2 or more disease-modifying anti-RA drugs, including methotrexate, are commonly used criteria.

CONCLUSIONS

The most important factors limiting access to biologic anti-RA treatment in the CEE region are macroeconomic conditions and restrictive treatment guidelines.

Health economic issues in rheumatoid arthritis

The objectives of treatment in rheumatoid arthritis (RA) are to reduce temporary symptoms due to inflammatory activity and, more importantly, to preserve function. The introduction of potent disease-modifying anti-rheumatic drugs (DMARDs) in recent years has increased the opportunities for effective treatment. However, these treatments come at a substantially higher cost than traditional DMARDs and therefore compete with other essential interventions for limited resources. They have triggered a debate on whether they represent an efficient use of resources, which patients should be treated, when, and for how long. Cost-effectiveness analysis attempts to estimate the trade-offs involved in these decisions and to provide information that can help in making them. However, in chronic progressive diseases, health gains and any potential associated economic benefits are often most evident in the long-term. As a consequence, the impact of new treatments has to be estimated using models that can project available knowledge, such as results from clinical trials or short-term follow-up studies in clinical practice, into the future. These models also allow scenarios to be explored that provide the best value for money, for example by defining subgroups for which treatment is most effective, or criteria that define when treatment should be stopped. Economic evaluation in RA has a long tradition, with the first study performed about 20 years ago. However, with the recent drug introductions, the field has witnessed an explosion of economic studies. Modelling techniques have become more sophisticated to overcome concerns about their validity. At the same time, they may appear less transparent, making it difficult for non-specialists to understand the details. This article, rather than reviewing all published models and comparing them, attempts to illustrate the inputs required for such studies, and the influence that different approaches and datasets can have on the results.

The burden of rheumatoid arthritis and access to treatment: health burden and costs

As part of the study "The burden of rheumatoid arthritis and patient access to treatment", this paper reviews evidence on the health burden of rheumatoid arthritis (RA) in terms of morbidity (DALYs), mortality (% of deaths attributable to RA) and quality of life (utility and loss of QALYs), as well as the economic impact on society. Based on available literature on the prevalence and the cost of RA, combined with economic indicators, the annual cost per patient as well as the total national cost is estimated for Europe and North America (Canada and the United States), as well as Australia, Turkey, the Russian Federation and South Africa. Total costs to society were estimated at <euro>45.3 billion in Europe and at <euro>41.6 billion in the United States. Utility scores were found to be amongst the lowest compared to other diseases.

The burden of rheumatoid arthritis and access to treatment: outcome and cost-utility of treatments

Within the series of articles investigating the burden of rheumatoid arthritis (RA), this paper reviews the methods used for economic assessment of the RA treatments by HTA agencies and other bodies involved in cost-effectiveness analysis and the current status of the field. The overall methods, as well as the challenges, of cost-effectiveness analysis in RA are common to all chronic progressive diseases where much of the treatment benefit is delayed, while costs occur immediately. Also, as in all disabling diseases, much of the costs occur outside the health-care system, due to the rapid loss of work capacity and the need for informal care in the later stages of the disease. Thus, it is essential to adopt a long-term view and consider costs from the perspective of society, rather than the health-care service, to increase the relevance of the results for policy making.

Thoughts on health economics in rheumatoid arthritis

In this manuscript we discuss the reasons why and how health economics is important, the type of economic studies that are relevant in healthcare to different stakeholders in general, and what analyses can and have been performed in the field of rheumatoid arthritis (RA). We will thus specifically address costs and outcome measurements in RA, as well as the need for modelling in chronic progressive diseases.