Comorbid conditions are associated with healthcare utilization, medical charges and mortality of patients with rheumatoid arthritis

Emergency department utilization by persons with rheumatoid arthritis: a population-based cohort study

Some emergency department (ED) visits by persons with rheumatoid arthritis (RA) may be avoidable. This study aims to describe ED use by persons with RA in Alberta, Canada over a 10-year period. Using linked population-based administrative datasets, the annual frequency of ED visits, timing of visits, acuity at presentation assessed (Canadian Triage Acuity Scale (CTAS)), return visits within 72 h, and final disposition were assessed. Most responsible diagnoses assessed by the ED provider were categorized. Between 2008 and 2017, a total of 48,633 persons with RA had 416,964 unique ED visits. There was a 41% relative increase in visits over the study period and within a fiscal year 37% of persons with RA on average attended an ED. Half of the visits were assessed as CTAS 4 'Less Urgent' (31%) and CTAS 5 'Non-Urgent' (19%). No specific diagnosis could be assigned in 36% of visits and RA was listed as the most responsible diagnosis in 2.5% of all visits. Hospital admissions, occurring on average for 14% of ED visits, increased by 15% over the 10 years, and were rare for CTAS 4 (6.4%) and CTAS 5 (1.4%) presentations. Male patients (difference to female 1.2%, 95%CI 0.6, 1.7) and urban patients (difference to rural 8.4%, 95%CI 7.7, 9.2) were more frequently admitted to hospital. Persons with RA have increased ED utilization over time, with a significant volume of less urgent and non-urgent visits. Opportunities for appropriate ambulatory care provision to reduce acute care use should be identified.

How do multiple long-term conditions impact on the cost-of-illness in early rheumatoid arthritis?

OBJECTIVE

Multiple long-term conditions (MLTCs) are prevalent in rheumatoid arthritis (RA) and associated with worse outcomes and greater economic burden. However, little is known about the impact of MLTCs on the cost-of-illness (COI) in early RA, including direct and indirect costs. The objective of this study was to quantify this impact on COI.

METHODS

The Scottish Early Rheumatoid Arthritis study is a national cohort of adults with new-onset RA. Direct costs were estimated applying relevant unit costs to health resource utilisation; indirect costs were measured by productivity loss due to health conditions. Two-part models were used, adjusting for age, gender, baseline functional disability and health-related quality of life. The Charlson Comorbidity Index score was calculated using ICD-10 diagnoses. Individuals were defined as 'RA alone', 'RA plus LTC' and 'RA plus MLTCs' according to the number of coexisting LTCs.

RESULTS

Data were available for 818 participants. Average annualised direct costs incurred by people with early RA plus MLTCs (£4444; 95% CI £3100 to £6371) were twice as, and almost five times higher than, those with a single LTC (£2184; 95% CI £1596 to £2997) and those without LTC (£919; 95% CI £694 to £1218), respectively. Indirect costs incurred by RA plus MLTCs (£842; 95% CI £377to £1521) were 3.1 times higher than RA alone (£530; 95% CI £273to £854). The relative proportion of direct costs increased with LTC category, ranging from 77.2% to 84.1%. In addition to increased costs with LTCs, costs also increased with age and were higher for men regardless of LTC category.

CONCLUSIONS

MLTCs impact on COI early in the course of RA. The presence of LTCs is associated with significant increases in both direct and indirect costs among people with early RA.

Diabetes-Related Complications and Costs in Medicare Beneficiaries with Comorbid Rheumatoid Arthritis and Diabetes Treated with Abatacept Versus Other Targeted DMARDs

INTRODUCTION

Targeted DMARD (tDMARD) use in patients with rheumatoid arthritis (RA) and type 2 diabetes mellitus (T2DM) may increase whole-body insulin sensitivity. Evidence comparing the T2DM-related clinical and economic impact of abatacept versus other tDMARDs is limited. This study compared differences in T2DM-related healthcare resource utilization (HCRU) and costs in patients with RA and T2DM.

METHODS

This retrospective study used 100% Medicare Fee-for-Service claims (parts A/B/D) to identify patients ≥ 65 age, diagnosed with RA and T2DM, and were either TNFi-experienced (switched from a TNFi to another tDMARD) or tDMARD-naïve, initiating their first tDMARD (abatacept, TNFi, or non-TNFi) between 2010 and 2017. Abatacept users were propensity-score (PS) matched to TNFi and other non-TNFi users separately on baseline demographics, comorbidities, medications, T2DM-related HCRU, and costs. Post-index follow-up: until discontinuation of index treatment, disenrollment, death, or end of study period, whichever occurred first. T2DM-related complications and HCRU were assessed. Costs were normalized to per-patient-per-month (PPPM) and inflated to 2019 US$.

RESULTS

The TNFi-experienced group included 2169 abatacept/TNFi and 2118 abatacept/other non-TNFi PS-matched pairs; the tDMARD-naïve group included 2667 abatacept/TNFi and 2247 abatacept/other non-TNFi PS-matched pairs. For TNFi-experienced patients, T2DM-related complication rates for inpatient settings PPPM trended lower for abatacept than TNFi (21 vs. 24, p = 0.046) and other non-TNFi groups (21 vs. 26; p < 0.0001). T2DM-related total costs PPPM for TNFi-experienced patients demonstrated lower trends for abatacept than TNFi ($489 vs. $594, p = 0.016) and other non-TNFi users ($493 vs. $606, p = 0.012).

CONCLUSIONS

Medicare beneficiaries with RA and T2DM who switch to/initiate abatacept as their first tDMARD have directionally lower rates and costs of T2DM-related complications compared with patients switching to/initiating other tDMARDs. Abatacept treatment may help reduce clinical and economic burdens associated with T2DM in patients with RA.

Self-Regulation Strategies Among Community-Dwelling People Aging With Arthritis and Multimorbidity

Self-regulation strategies of selection, optimization, and compensation (SR-SOC) have been found to predict arthritis self-efficacy and quality of life among community-dwelling people aging with arthritis and multimorbidity. The current study aimed to describe the health resources and chronic disabling symptom characteristics of community-dwelling people aging with arthritis and multimorbidity and investigate how these characteristics influence and predict SR-SOC strategies in managing arthritis multimorbidity after controlling for demographics and comorbidities. One hundred forty individuals aged >50 years completed surveys on demographics, comorbidities, health resources, symptoms, and SR-SOC strategy use frequencies. Descriptive statistics were used to describe sample characteristics. Correlations and multivariate hierarchical stepwise regressions were used to examine the associated characteristics and predictors for SR-SOC strategy use frequency. Lower health literacy, health care provider communication quality, and smaller social network were reported less often than arthritis in general. Significant predictors of SR-SOC strategy use were physical symptoms, health care provider communication quality, and age (p < 0.05). Better symptom management and health care provider communication quality could help promote self-regulation. [Journal of Gerontological Nursing, 47(1), 35-45.].

Healthcare Costs of Not Achieving Remission in Patients with Rheumatoid Arthritis in the United States: A Retrospective Cohort Study

Introduction

To compare all-cause and rheumatoid arthritis (RA)-related healthcare costs and resource use in patients with RA who do not achieve remission versus those who achieve remission, using clinical practice data.

Methods

Data were derived from Optum electronic health records linked to claims from commercial and Medicare Advantage health plans. Two cohorts were created: remission and non-remission. Remission was defined as Disease Activity Score 28-joint count with the C-reactive protein level or erythrocyte sedimentation rate (DAS28-CRP/ESR) < 2.6 or Routine Assessment of Patient Index Data 3 (RAPID3 ≤ 3.0). Outcomes were all-cause and RA-related costs and resource use during a 1-year follow-up period. A weighted generalized linear regression and negative binomial regression were used to estimate adjusted annual costs and resource use, respectively, controlling for confounding factors, including patient and socio-demographic characteristics.

Results

Data from 335 patients (remission: 125; non-remission: 210) were analyzed. Annual all-cause total costs were significantly less in the remission versus non-remission cohort ($30,427 vs. $38,645, respectively; cost ratio [CR] = 0.79; 95% CI 0.63, 0.99). All-cause resource use (mean number of visits) was less in the remission versus non-remission cohort: inpatient (0.23 vs. 0.63; visit ratio [VR] = 0.36; 95% CI 0.19, 0.70), emergency department (0.36 vs. 0.77; VR = 0.47; 95% CI 0.30, 0.74), and outpatient visits (20.7 vs. 28.5; VR = 0.73; 95% CI 0.62, 0.86). Annual RA-related total costs were similar in both cohorts; however, RA-related medical costs were numerically lower in the remission versus non-remission cohort ($8,594 vs. $10,002, respectively; CR = 0.86; 95% CI 0.59, 1.25). RA-related resource use was less in the remission versus non-remission cohort.

Conclusions

Significant economic burden was associated with patients who did not achieve remission compared with those who did achieve remission.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01730-w.

Bone mineral density and microarchitecture among Chinese patients with rheumatoid arthritis: a cross-sectional study with HRpQCT

BACKGROUND

Patients with rheumatoid arthritis (RA) are at increased risk of fractures. Although their decline in bone mineral density (BMD) is well-established, data regarding the alterations in bone microarchitecture are limited. In this study, we aimed to evaluate bone microarchitecture, geometry, and volumetric BMD among patients with RA in mainland China using high-resolution peripheral quantitative computed tomography (HRpQCT).

METHODS

In this cross-sectional study, patients with RA were recruited from the Peking Union Medical College Hospital site of the Chinese Registry of rhEumatoiD arthrITis (CREDIT). Each participant underwent HRpQCT scanning (Scanco XtremeCT II), thoracolumbar X-ray and dual-energy X-ray absorptiometry. The primary outcomes were HRpQCT-related measures at distal radius and tibia. Data regarding demographic features, RA-related characteristics, and history of fragility fractures were collected. Correlation between HRpQCT parameters and potentially related factors were analyzed using linear regression analysis. A group of age- and sex-matched healthy controls was included for comparison.

RESULTS

A total of 81 patients with RA [69 women, aged 57.9 ± 8.7 years, disease duration 5.7 (IQR 1.4-11.2) years] and 81 matched healthy controls were included. Compared with controls, patients with RA had significantly larger bone area and lower total and trabecular vBMD at both the distal radius and tibia. Lower cortical bone thickness was also shown at the distal tibia. Among patients with RA, advanced age, low BMI, female sex, disease duration, and activity were associated with decreased vBMD and impaired bone microstructure. Female reproductive factors including menopause, late menarche, breast feeding, and early childbirth also showed negative correlation with these parameters. Compared to patients with RA without fractures, patients with fragility fractures (n = 11) showed lower trabecular and cortical vBMD, thinner cortical bone, impaired trabecular microstructure, and a trend of declined bone strength. Current glucocorticoid intake was related to decreased vBMD, trabecular number, increased trabecular separation, and inhomogeneity.

CONCLUSIONS

In this study, we observed alterations in bone mineral density, geometry, and microarchitecture among patients with RA compared to healthy individuals, which may impair bone strength and lead to increased risk of fractures. Both traditional risk factors for osteoporosis and RA-associated factors need to be considered in the assessment of the bone quality.

Risk and cost of infection-related hospitalizations in medicare beneficiaries with comorbid rheumatoid arthritis treated with abatacept versus other targeted disease-modifying anti-rheumatic drugs

OBJECTIVE

This study evaluated infection-related hospitalization risk and cost in tumor necrosis factor inhibitor (TNFi)-experienced and targeted DMARD (tDMARD) naïve rheumatoid arthritis (RA) patients that were treated with abatacept, TNFi, or other non-TNFi.

METHODS

This retrospective study used 100% Medicare Fee-for-Service claims to identify patients ≥65 age, diagnosed with RA, and were either 1) TNFi-experienced, who switched from a TNFi to another tDMARD (subsequent tDMARD claim served as index), or 2) tDMARD naïve (first therapy claim served as index), who initiated either abatacept, TNFi, or non-TNFi as their first tDMARD, between 2010 and 2017. Follow-up ended at the date of disenrollment, death, end of study period, or end of index treatment, whichever occurred first. Infection-related hospitalizations included pneumonia, bacterial respiratory, sepsis, skin and soft tissue, joint or genitourinary infections. A Cox proportional hazard model and two part generalized linear model were developed to estimate adjusted infection-related hospitalization risk and costs. Costs were normalized to per-patient-per-month (PPPM) and inflated to 2019 US$.

RESULTS

The infection-related hospitalizations rate was lower during follow-up than during baseline periods for abatacept users, but was reversed for both TNFi and other non-TNFi users in both TNFi-experience and tDMARD naïve (p value < .001 based on Breslow-Day test for homogeneity of odds ratios). Infection-related hospitalization PPPM cost was significantly lower in abatacept treated patients compared to TNFi (TNFi-experienced: by $74; tDMARD naïve: $42) and other non-TNFi (TNFi-experienced: by $68; tDMARD naïve: $60). The adjusted infection-related hospitalization risk was significantly higher for RA patients treated with TNFi (TNFi-experienced HR: 1.48; 95% CI: 1.26-1.75, p < .0001; tDMARD naïve HR:1.59; 95% CI: 1.43-1.77, p < .0001) and other non-TNFi (TNFi-experienced HR:1.46; CI:1.28-1.66; tDMARD naïve HR:1.63; 95% CI: 1.44-1.83) than with abatacept.

CONCLUSION

RA Medicare Fee-For-Service beneficiaries who either switched or initiated abatacept have a lower infection-related hospitalization risk and cost compared to patients who switched to or initiated other tDMARDs.

Impact of Comorbid Conditions on Healthcare Expenditure and Work-related Outcomes in Patients With Rheumatoid Arthritis

OBJECTIVE

To evaluate the effect of comorbid conditions on direct healthcare expenditure and work-related outcomes in patients with rheumatoid arthritis (RA).

METHODS

This is a retrospective analysis of the Medical Expenditure Panel Survey from 2006 to 2015 in 4967 adults with RA in the United States. Generalized linear models were used for healthcare expenditure and income, logistic models for employment status, and zero-inflated negative binomial models for absenteeism. Thirteen comorbid conditions were included as potential predictors of direct cost- and work-related outcomes. The models were adjusted for sociodemographic factors including sex, age, region, marital status, race/ethnicity, income, education, and smoking status.

RESULTS

Patients with RA with heart failure (HF) had the highest incremental annual healthcare expenditure (US$8205, 95% CI $3683-$12,726) compared to those without the condition. Many comorbid conditions including hypertension (HTN), diabetes, depression, chronic obstructive pulmonary disease, cancer, stroke, and HF reduced the chance of patients with RA aged between 18-64 years being employed. Absenteeism of employed patients with RA was significantly affected by HTN, depression, disorders of the eye and adnexa, or stroke. On average, RA patients with HF earned US$15,833 (95% CI $4435-$27,231) per year less than RA patients without HF.

CONCLUSION

Comorbid conditions in patients with RA were associated with higher annual healthcare expenditure, lower likelihood of employment, higher rates of absenteeism, and lower income. Despite its low prevalence, HF was associated with the highest incremental healthcare expenditure and the lowest likelihood of being employed compared to other common comorbid conditions.

The Risk of Cardiovascular Events Associated With Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis

OBJECTIVE

To examine the comparative effects of biologic disease-modifying antirheumatic drugs (bDMARD) and tofacitinib against conventional synthetic DMARD (csDMARD) on incident cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA).

METHODS

RA patients with ≥ 1 year of participation in the FORWARD study, from 1998 through 2017, were assessed for incident composite CVD events (myocardial infarction, stroke, heart failure, and CVD-related death validated from hospital/death records). DMARD were categorized into 7 mutually exclusive groups: (1) csDMARD-referent; (2) tumor necrosis factor-α inhibitor (TNFi); (3) abatacept (ABA); (4) rituximab; (5) tocilizumab; (6) anakinra; and (7) tofacitinib. Glucocorticoids (GC) were assessed using a weighted cumulative exposure model, which combines information about duration, intensity, and timing of exposure into a summary measure by using the weighted sum of past oral doses (prednisolone equivalent). Cox proportional hazard models were used to adjust for confounders.

RESULTS

During median (IQR) 4.0 (1.7-8.0) years of follow-up, 1801 CVD events were identified in 18,754 RA patients. The adjusted model showed CVD risk reduction with TNFi (HR 0.81, 95% CI 0.71-0.93) and ABA (HR 0.50, 95% CI 0.30-0.83) compared to csDMARD. While higher GC exposure as weighted cumulative exposure was associated with increased CVD risk (HR 1.15, 95% CI 1.11-1.19), methotrexate (MTX) use was associated with CVD risk reduction [use vs nonuse HR 0.82, 95% CI 0.74-0.90, and high dose (> 15 mg/week) vs low dose (≤ 15 mg/week) HR 0.83, 95% CI 0.70-0.99].

CONCLUSION

ABA and TNFi were associated with decreased risk of CVD compared to csDMARD. Minimizing GC use and optimizing MTX dose may improve cardiovascular outcomes in patients with RA.

Impact of Psychiatric Comorbidity on Health Care Use in Rheumatoid Arthritis: A Population-Based Study

Objective

Psychiatric comorbidity is frequent in rheumatoid arthritis (RA) and complicates treatment. The present study was undertaken to describe the impact of psychiatric comorbidity on health care use (utilization) in RA.

Methods

We accessed administrative health data (1984–2016) and identified a prevalent cohort with diagnosed RA. Cases of RA (n = 12,984) were matched for age, sex, and region of residence with 5 controls (CNT) per case (n = 64,510). Within each cohort, we identified psychiatric morbidities (depression, anxiety, bipolar disorder, and schizophrenia [PSYC]), with active PSYC defined as ≥2 visits per year. For the years 2006–2016, annual rates of ambulatory care visits (mean ± SD per person) categorized by provider (family physician [FP], rheumatologist, psychiatrist, other specialist), hospitalization (% of cohort), days of hospitalization (mean ± SD), and dispensed drug types (mean ± SD per person) were compared among 4 groups (CNT, CNT plus PSYC, RA, and RA plus PSYC) using generalized linear models adjusted for age, sex, rural versus urban residence, income quintile, and total comorbidities. Estimated rates are reported with 95% confidence intervals (95% CIs). We tested within‐person and RA‐PSYC interaction effects.

Results

Subjects with RA were mainly female (72%) and urban residents (59%), with a mean ± SD age of 54 ± 16 years. Compared to RA without PSYC, RA with PSYC had more than additive (synergistic) visits (standardized mean difference [SMD] 10.92 [95% CI 10.25, 11.58]), hospitalizations (SMD 13% [95% CI 0.11, 0.14]), and hospital days (SMD 3.63 [95% CI 3.06, 4.19]) and were dispensed 6.85 more medication types (95% CI 6.43, 7.27). Cases of RA plus PSYC had increased visits to FPs (an additional SMD 8.92 [95% CI 8.35, 9.46] visits). PSYC increased utilization in within‐person models.

Conclusion

Managing psychiatric comorbidity effectively may reduce utilization in RA.

Increased hospitalization rates following heart failure diagnosis in rheumatoid arthritis as compared to the general population

OBJECTIVE

To compare the frequency of and trends in hospitalizations after heart failure (HF) diagnosis in patients with and without rheumatoid arthritis (RA) during 1987-2015.

METHODS

The study included a retrospectively identified population-based cohort of patients with incident HF and prior RA (age≥18 years, 1987 ACR criteria) and a cohort of incident HF patients without RA matched 3:1 on age, sex, and year of HF diagnosis. Hospitalizations at the time of HF diagnosis were excluded. All subjects were followed until death, migration, or 12/31/2015.

RESULTS

The study included 212 patients with RA (mean age at HF diagnosis 78.3 years; 68% female) and 636 non-RA patients (mean age at HF diagnosis 78.6 years; 68% female). The hospitalization rate after HF diagnosis was higher in RA vs non-RA (rate ratio [RR] 1.17; 95%CI 1.08-1.26). Hospitalization rates in both groups have been declining since 2005 and the difference between patients with and without RA may be decreasing after 2010. The magnitude of the increase was similar in both sexes and across all ages. Patients with RA were more likely to be hospitalized for non-cardiovascular causes (RR 1.26; 95%CI 1.14-1.39), but not for HF or other cardiovascular causes compared to non-RA patients.

CONCLUSIONS

The hospitalization rate following HF diagnosis was higher in RA versus non-RA patients regardless of sex and age. Increased hospitalization risk in patients with RA was driven by increased rates of non-cardiovascular hospitalization.

Validity of adopting a Health Assessment Questionnaire Disability Index less than 0.5 as a target in elderly rheumatoid arthritis patients

OBJECTIVES

The effect of age on the Health Assessment Questionnaire Disability Index (HAQ-DI) scores of rheumatoid arthritis (RA) patients and the validity of adopting HAQ-DI < 0.5 as the target for functional remission and comprehensive disease control (CDC) under a treat-to-target (T2T) treatment strategy were investigated.

METHOD

A total of 441 RA patients with > 3-year treatment under T2T were evaluated. The relationships between the HAQ-DI score at follow-up (HAQ) and 28-joint Disease Activity Score with C-reactive protein, Sharp/van der Heijde Score, age at follow-up, and HAQ-DI at baseline were statistically evaluated with best subset regression analysis in groups separated according to age and the EULAR response. CDC status was evaluated with a chi-square test.

RESULTS

The HAQ score significantly correlated with all indices in the group ≥ 65 years old (G-O) and in the group with good or moderate EULAR responses (p < 0.01). No significant correlation was observed in the group < 65 years old (G-Y) or in the group with no EULAR response. The CDC ratio was not significantly different between the age groups, whereas the HAQ failure ratio was significantly greater in G-O than in G-Y (p < 0.01). No significant difference was found between the EULAR response groups.

CONCLUSIONS

The HAQ score is influenced by age in patients > 65 years. T2T is appropriate for attaining good disease activity control but does not always lead to functional remission in these patients. The HAQ score < 0.5 is not an appropriate target for functional remission according to the CDC criteria for elderly patients.Key Points• ADL in elderly RA patient aged ≥ 65 years declines corresponding to his/her aging.• Functional remission for elderly RA patients is not the same as that for young RA patients.• The HAQ score < 0.5 in elderly RA patient is not an appropriate target for CDC.

Chronic obstructive pulmonary disease in rheumatoid arthritis: a systematic review and meta-analysis

BACKGROUND

The risk and prevalence of chronic obstructive pulmonary disease (COPD) in rheumatoid arthritis (RA) is still obscure. The current study was aimed to systematically review and meta-analyse the risk ratio (RR) and prevalence of COPD in RA.

METHODS

A comprehensive systematic review was conducted based on PubMed, Web of Science and Cochrane Library from inception to April 30, 2018. The primary outcome of our study was the RR of COPD in RA patients compared with controls, and secondary was the prevalence of COPD in RA patients. Pooled effect sizes were calculated according to fixed effect model or random effects model depending on heterogeneity.

RESULTS

Six and eight studies reported the RR and prevalence of COPD in RA respectively. Compared with controls, RA patients have significant increased risk of incident COPD with pooled RR 1.82 (95% CI = 1.55 to 2.10, P <  0.001). The pooled prevalence of COPD in RA patients was 6.2% (95% CI = 4.1 to 8.3%). Meta-regression identified that publication year was an independent covariate negatively associated with the RR of COPD, and smoker proportion of RA population was also positively associated with the prevalence of COPD significantly in RA patients.

CONCLUSIONS

The present meta-analysis has demonstrated the significant increased risk and high prevalence of COPD in RA patients. Patients with RA had better cease tobacco use and rheumatologists should pay attention to the monitoring of COPD for the prevention and control of COPD.

Influence of disease duration and socioeconomic factors on the prevalence of infection and hospitalization in rheumatoid arthritis: KRAC study

AIM

The use of healthcare resources by rheumatoid arthritis (RA) patients can be related to the presence of disease, comorbid conditions, use of steroids, and the combined use of immunosuppressants. This study evaluated the risk factors associated with infection and hospitalization in RA.

METHODS

This multicenter, cross-sectional study enrolled 3247 RA subjects fulfilling the 2010 American College of Rheumatology/European League Against Rheumatism criteria to examine the prevalence of hospitalization and episodes of documentable non-tubercular infections as a part of the "Karnataka rheumatoid arthritis comorbidity" study (KRAC). The study included 2081 subjects and 1166 were excluded due to incomplete data. Demographic, clinical and treatment variables were collected, and the events related to infections and hospitalization were extracted from the medical records. Comparative analysis and multivariate logistic regression were performed.

RESULTS

Around 22% of the subjects had hospitalizations and 2.9% had infections. Infections were pertaining to dental (1.3%), urinary tract (1.6%) and candidiasis (0.2%). Skin- and soft tissue-related infections were found in 1.8% and 0.3% of patients, respectively. Increased need of hospitalization in RA patients was associated with advanced age (≥60 years), lower education, family income, and longer duration of RA. Presence of comorbidity, usage of three or more disease-modifying anti-rheumatic drugs (DMARDs) and family income influenced the likelihood of infection. Dental infections were less likely in working subjects and more likely in patients with increased disease duration, higher family income, comorbidities and those between the age group 40-59 years. Urinary tract infection was associated with DMARD usage.

CONCLUSION

Patient-specific risk factors should be considered to improve treatment strategies and to reduce the risk of infection and hospitalization in RA patients.

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.

Risk of Incident Chronic Obstructive Pulmonary Disease in Rheumatoid Arthritis: A Population-Based Cohort Study

OBJECTIVE

Studies have demonstrated a link between chronic obstructive pulmonary disease (COPD) and inflammation, raising the question whether chronic inflammatory conditions, such as rheumatoid arthritis (RA), predispose to COPD. Our objective was to evaluate the risk of incident COPD hospitalization in RA compared to the general population.

METHODS

We studied a population-based incident RA cohort with matched general population controls, using administrative health data. All incident RA cases in British Columbia who first met RA definition between January 1996 and December 2006 were selected using previously published criteria. General population controls were randomly selected, matched 1:1 to RA cases on birth year, sex, and index year. COPD outcome was defined as hospitalization with a primary COPD code. Incidence rates, 95% confidence intervals (95% CIs), and incidence rate ratios (IRRs) were calculated for RA and controls. Multivariable Cox proportional hazards models estimated the risk of COPD in RA compared to the general population after adjusting for potential confounders. Sensitivity analyses were performed to test the robustness of the results to the possible confounding effect of smoking, unavailable in administrative data, and to COPD outcome definitions.

RESULTS

The cohorts included 24,625 RA individuals and 25,396 controls. The incidence of COPD hospitalization was greater in RA than controls (IRR 1.58, 95% CI 1.34-1.87). After adjusting for potential confounders, RA cases had a 47% greater risk of COPD hospitalization than controls. The increased risk remained significant after modeling for smoking and with varying COPD definitions.

CONCLUSION

In our population-based cohort, individuals with RA had a 47% greater risk of COPD hospitalization compared to the general population.

Changes in Healthcare Utilization After Etanercept Initiation in Patients with Rheumatoid Arthritis: A Retrospective Claims Analysis

Introduction

Effective treatment for rheumatoid arthritis (RA) may lead to lower overall and RA-related healthcare utilization. We evaluated healthcare utilization before and after initiation of the tumor necrosis factor inhibitor etanercept in patients with moderate to severe RA.

Methods

This retrospective cohort study used data from the MarketScan^® claims database. Data from adult patients with RA newly exposed to etanercept between January 1, 2010 and December 31, 2013 were analyzed. Patients had at least one inpatient or outpatient claim for RA and at least one claim for etanercept (first claim was index date). Etanercept compliance was determined on the basis of proportion of days covered (PDC). Primary outcome was change in overall and RA-related healthcare utilization in the year before and year after etanercept initiation. McNemar’s test and paired t test, respectively, were used to determine statistical significance for dichotomous and continuous variables.

Results

Data from 6737 patients were analyzed; mean age was 49.8 years and 77.3% were female. Overall outpatient services, office visits, outpatient hospital services, laboratory visits, and emergency department visits were significantly lower in the post-index period compared to pre-index. RA-related pharmacotherapy use (oral corticosteroids, opioid analgesics, nonsteroidal anti-inflammatory drugs, and nonbiologic disease-modifying antirheumatic drugs) was significantly lower in the post-index period compared to pre-index. Rates of RA-related total joint arthroplasty, joint reconstructions, and soft tissue procedures were similar in pre-index and post-index periods. High etanercept compliance (PDC ≥80%) was associated with significantly lower rates of RA-related outpatient services, office visits, diagnostic imaging studies, and joint reconstructions compared with noncompliance.

Conclusion

Overall healthcare utilization decreased after etanercept initiation. Patients who were most compliant with etanercept had significantly lower utilization than less compliant patients.

Funding

Amgen, Inc

A Longitudinal Study of Ambulatory Physician Encounters, Emergency Room Visits, and Hospitalizations by Patients with Rheumatoid Arthritis: A 13-year Population Health Study

Objective.

To determine total physician encounters, emergency room (ER) visits, and hospitalizations in an incident cohort of rheumatoid arthritis (RA) cases and matched control patients over 13 years.

Methods.

A retrospective cohort study was performed using administrative healthcare data from about 1 million people with access to universal healthcare. Using the International Classification of Diseases, 9th ed (ICD-9) and ICD-10 diagnostic codes, 7 RA case definitions were used. Each case was matched by age and sex to 4 randomly selected controls. Data included physician billings, ER visits, and hospital discharges over 13 years.

Results.

The number of incident RA cases varied from 3497 to 27,694, depending on the case definition. The mean age varied from 54.3 to 65.0 years, and the proportion of women from 67.8% to 71.3%. The number of physician encounters by patients with RA was significantly higher than by controls. It was highest in the index year and declined promptly thereafter for all case definitions and by 12.2%–46.8% after 10 years. Encounters with subspecialty physicians fell by 61% (rheumatologists) and 34% (internal medicine). In contrast, clinical encounters with family physicians and other physicians fell by only 9%. Visits to the ER and hospital admissions were also significantly higher in RA cases, particularly early in the disease, and fell significantly over the followup.

Conclusion.

In patients with RA, healthcare use is highest in the first year following the diagnosis, which is also the time of maximal involvement by rheumatologists. Use declines over time, and encounters with patients’ family physicians predominate over other physician groups.