Developing and externally validating multinomial prediction models for methotrexate treatment outcomes in patients with rheumatoid arthritis: results from an international collaboration

OBJECTIVES

In rheumatology, there is a clinical need to identify patients at high risk (>50%) of not responding to the first-line therapy methotrexate (MTX) due to lack of disease control or discontinuation due to adverse events (AEs). Despite this need, previous prediction models in this context are at high risk of bias and ignore AEs. Our objectives were to (i) develop a multinomial model for outcomes of low disease activity and discontinuing due to AEs 6 months after starting MTX, (ii) update prognosis 3-month following treatment initiation, and (iii) externally validate these models.

STUDY DESIGN AND SETTING

A multinomial model for low disease activity (submodel 1) and discontinuing due to AEs (submodel 2) was developed using data from the UK Rheumatoid Arthritis Medication Study, updated using landmarking analysis, internally validated using bootstrapping, and externally validated in the Norwegian Disease-Modifying Antirheumatic Drug register. Performance was assessed using calibration (calibration-slope and calibration-in-the-large), and discrimination (concordance-statistic and polytomous discriminatory index).

RESULTS

The internally validated model showed good calibration in the development setting with a calibration-slope of 1.01 (0.87, 1.14) (submodel 1) and 0.83 (0.30, 1.34) (submodel 2), and moderate discrimination with a c-statistic of 0.72 (0.69, 0.74) and 0.53 (0.48, 0.59), respectively. Predictive performance decreased after external validation (calibration-slope 0.78 (0.64, 0.93) (submodel 1) and 0.86 (0.34, 1.38) (submodel 2)), which may be due to differences in disease-specific characteristics and outcome prevalence.

CONCLUSION

We addressed previously identified methodological limitations of prediction models for outcomes of MTX therapy. The multinomial approach predicted outcomes of disease activity more accurately than AEs, which should be addressed in future work to aid implementation into clinical practice.

Explaining the gap in the experience of depression among arthritis patients

OBJECTIVE

To explain the factors contributing to the gap in depression between employed arthritis patients with and without paid sick leave.

METHODS

Blinder-Oaxaca decomposition analysis was used to identify factors that explain the gap in the experience of depressive symptoms among arthritis patients with paid and unpaid sick leave. Data from the 2018 National Health Interview Survey, USA, was used.

RESULTS

A total of 7189 of the NHIS survey participants given the diagnosis of arthritis were identified, of which 39% were male and 61% were female, with mean age of 63.5 years. The decomposition findings suggest patients in the unpaid sick leave group were more likely to report depressive symptoms compared to patients with paid sick leave. The major contributors to the gap in the report of depressive symptoms are sex (female) and annual income (less than 35,000 USD).

CONCLUSION

Findings suggest that the absence of paid sick leave is a key determinant for experiencing depressive symptoms among individuals with arthritis. The provision of paid sick leave may reduce report of depressive symptoms among employed arthritis patients in the USA.

KEY POINTS

• Individuals with arthritis are consistently at greater risk of depression and unemployment as compared to individuals without arthritis. • To date greater emphasis is put on determinants of unemployment, while there is no available data on benefits associated with being employed, such as sick leave, and how it affects mental health. • Patients with unpaid sick leave appear to experience more persistent depressive symptoms than patients with access to paid sick leave. • To tackle burden of depression among arthritis patients, provision of paid sick leave may be an effective intervention.

Achievement of more stringent disease control is associated with reduced burden on workplace and household productivity: results from long-term certolizumab pegol treatment in patients with psoriatic arthritis

Background:

Psoriatic arthritis (PsA) impacts the physical health and functional ability of patients, leading to reduced productivity. High unemployment rates and absence due to sickness have been reported in patients with PsA.

Objectives:

This post hoc study investigated certolizumab pegol treatment impact on workplace and household productivity in patients with PsA, and assessed whether achievement of more stringent disease control was associated with greater improvements in productivity.

Design:

RAPID-PsA was a 216-week phase III trial.

Methods:

This post hoc study used a generalised estimating equations (GEE) model to examine the disease activity association, measured using American College of Rheumatology (ACR) and Disease Activity in PSoriatic Arthritis (DAPSA), and workplace and household productivity, assessed using an arthritis-specific Work Productivity Survey (WPS). The GEE model estimated the mean cumulative number of days patients meeting different disease control criteria were affected by absenteeism or presenteeism in the workplace and household.

Results:

In all, 273 patients were randomised to certolizumab pegol and 183 (67.0%) completed Week 216. At baseline, 60.8% of patients were employed outside the home. Improved disease control, measured using ACR and DAPSA criteria, was associated with fewer cumulative days affected by workplace absenteeism through Week 216: ACR70: 4.1 days, ACR50 to <70: 7.7, ACR20 to <50: 20.9, <ACR20: 35.7; DAPSA remission (REM): 3.3, low disease activity (LDA): 9.8, moderate disease activity (MoDA): 22.4, high disease activity (HDA): 54.0. Improved disease control was also associated with fewer days affected by workplace presenteeism: ACR70: 5.6, ACR50 to <70: 19.3, ACR20 to <50: 71.2, < ACR20: 141.2; DAPSA REM: 5.7, LDA: 25.8, MoDA: 77.2, HDA: 223.6. Similar associations between greater disease control and improved productivity were observed for household absenteeism and presenteeism.

Conclusion:

This post hoc study demonstrates the cumulative workplace and household work productivity benefits for patients with PsA when achieving more stringent thresholds of disease control with certolizumab pegol treatment.

Pain and Fatigue in Patients With Ankylosing Spondylitis Treated With Tumor Necrosis Factor Inhibitors: Multinational Real-World Findings

BACKGROUND/OBJECTIVE

Patients with ankylosing spondylitis (AS) experience symptoms and comorbidities that impact their health-related quality of life (HRQoL) and ability to work. This real-world, global survey was conducted among AS patients receiving tumor necrosis factor inhibitors (TNFis) to evaluate both the frequency and severity of persistent symptoms, and the impact of pain and fatigue on HRQoL, employment status, and work activity.

METHODS

Patients with AS and their treating physicians from 13 countries across 5 continents completed questionnaires capturing demographics, patient symptoms, current disease status, HRQoL, current therapy, employment status, and Work Productivity and Activity Impairment.

RESULTS

Seven hundred five patients who had been receiving a TNFi for 3 months or more and completed both Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) pain and fatigue domains were included in the analysis; of these, 37.6% reported high BASDAI pain scores and 41.3% high BASDAI fatigue scores. Medical Outcomes Study-Short Form, 36-item version 2 domain, 5-dimensional EuroQoL Questionnaire, and 5-dimensional EuroQoL visual analog scale scores were significantly lower (p < 0.0001), and Work Productivity and Activity Impairment scores significantly higher (p < 0.0001), in patients with high levels of pain or fatigue than low levels.

CONCLUSIONS

Globally, levels of pain and fatigue remained high in AS patients receiving TNFi treatment, which were significantly associated with reduced HRQoL and work productivity. Such persistent symptoms in usual care suggest a substantial unmet need in AS pharmacologic and nonpharmacologic therapeutic pathways.

Healthcare utilization and economic burden of difficult-to-treat rheumatoid arthritis: a cost-of-illness study

OBJECTIVES

To determine the impact of difficult-to-treat rheumatoid arthritis (D2T RA) on (costs related to) healthcare utilization, other resource use and work productivity.

METHODS

Data regarding healthcare utilization, other resource use and work productivity of 52 D2T (according to the EULAR definition) and 100 non-D2T RA patients were collected via a questionnaire and an electronic patient record review during a study visit. Annual costs were calculated and compared between groups. Multivariable linear regression analysis was performed to assess whether having D2T RA was associated with higher costs.

RESULTS

Mean (95% CI) annual total costs were €37 605 (€27 689 - €50 378) for D2T and €19 217 (€15 647 - €22 945) for non-D2T RA patients (P<0.001). D2T RA patients visited their rheumatologist more frequently, were more often admitted to day-care facilities, underwent more laboratory tests and used more drugs (specifically targeted synthetic DMARDs), compared with non-D2T RA patients (P<0.01). In D2T RA patients, the main contributors to total costs were informal help of family and friends (28%), drugs (26%) and loss of work productivity (16%). After adjustment for physical functioning (HAQ), having D2T RA was no longer statistically significantly associated with higher total costs. HAQ was the only independent determinant of higher costs in multivariable analysis.

CONCLUSIONS

The economic burden of D2T RA is significantly higher than that of non-D2T RA, indicated by higher healthcare utilization and higher annual total costs. Functional disability is a key determinant of higher costs in RA.

Relationship of pain and fatigue with health-related quality of life and work in patients with psoriatic arthritis on TNFi: results of a multi-national real-world study

BACKGROUND/OBJECTIVE

The incidence of pain and/or fatigue in people with psoriatic arthritis (PsA) is associated with reduced health-related quality of life (HRQoL) and the ability to work, despite modern advanced therapeutic approaches. This real-world, international study examined these relationships in patients with PsA treated with tumour necrosis factor inhibitors (TNFi).

METHODS

Data from 13 countries were analysed. Patients with PsA and their physicians completed questionnaires capturing demographics, current therapy, current disease status, HRQoL and work status via Medical Outcomes Study 36-Item Short-Form version 2 (SF-36v2), 3-level 5-dimension EuroQoL questionnaire, Health Assessment Questionnaire Disability Index, and Work Productivity and Activity Impairment (WPAI) questionnaire.

RESULTS

640 patients with PsA were included who had been receiving TNFi for ≥3 months and had completed SF-36v2 bodily pain and vitality domains. Of these, 33.1%, 29.2% and 37.7% of patients reported no, moderate and severe pain, respectively, and 31.9%, 22.5% and 45.6% of patients reported low, moderate and severe fatigue, respectively. Scores across HRQoL variables and WPAI were significantly different across pain and fatigue cohorts (all p<0.0001), with HRQoL and WPAI measures considerably worse in patients with moderate to severe pain or fatigue than those with low pain or fatigue.

CONCLUSIONS

Despite treatment with biologic agents such as TNFi, data from this global study demonstrated that substantial pain and/or fatigue persist in patients with PsA and that these are significantly associated with reduced HRQoL, physical function and work productivity. These findings suggest that there is an unmet need for additional PsA therapies.

Estimation of direct cost of managing rheumatoid arthritis treatment to Pakistani patients using real-world follow-up data

OBJECTIVE

This study aimed to estimate annual direct cost attributed to rheumatoid arthritis (RA) treatment from a patient's perspective using real-world patient follow-up data from hospitals' electronic database.

METHODS

A prospective 1-year study was conducted in rheumatology clinics of tertiary care hospitals of Karachi, Pakistan. Cost-of-illness methodology was used and all patient data related to costs of rheumatologist visits, physical therapy sessions, medications, assistive devices and laboratory investigations were obtained directly in printed hardcopies from patient electronic databases using their medical record numbers. Transportation cost was calculated from patient-reported log books. Data were analyzed through IBM SPSS version 23. Patients were asked to sign a written consent and the study was ethically approved.

RESULTS

The mean age of patients (N = 358) was 48 years. Most patients (73.7%) were female, married (86%) and had basic education (71.8%). Average cost of rheumatologist visits was PKR 11 510.61 (USD: 72.05) while it was PKR 66 947.37 (USD: 419.07) for physical therapy sessions. On average, medicines and medical devices costs were estimated at PKR 10 104.23 (USD: 63.25) and PKR 7848.48 (USD: 49.13) respectively. Cost attributed to diagnostic and laboratory charges was PKR 1962.12 (USD: 12.28) and travel expense was PKR 6541 (USD: 40.95). The direct expenditure associated with managing RA was PKR 37 558 (USD: 235.1). All costs were reported per annum.

CONCLUSION

Patient with RA in Pakistan pay a considerable amount of their income for managing their condition. Most patients have no provision for insurance which is a need considering the nature of the disease and associated productivity loss that would significantly lower income as the disease progresses.

Current stepwise recommendations for hypogonadism screening in erectile dysfunction are not cost-effective

Hypogonadism is a prevalent comorbidity with erectile disfunction (ED) and current guidelines recommend screening for hypogonadism with total testosterone (TT). If low TT is detected, further assessment with LH and SHBG plus albumin are needed to establish an etiology and treatment. Our primary objective was to determine the cost benefit of current stepwise approach versus ad initium full hormonal assessment. Two hundred consecutive male patients referred for ED were screened after consent and 81 were included and assessed for hypogonadism according to the current stepwise approach with TT, and only if TT was less than 345 ng/mL, a full hormonal assessment with TT, LH, and SHBG plus albumin to calculate free testosterone was performed. Direct costs were calculated using the national public healthcare system reimbursement tables and were compared with a hypothetical initial full hormonal assessment. Screening TT was less than 345 ng/mL in 34.6% patients leading to a full hormonal assessment on these. Using a stepwise approach there was a direct cost increase of 5.82 € per patient. Moreover, one out of every three patients had two extra venipunctures and an additional follow-up appointment. Current stepwise recommendations may prove costly in high prevalence scenarios such as the ED subpopulation as a direct cost increase was observed.

Direct healthcare costs and comorbidity burden among patients with psoriatic arthritis in the USA

This study assessed the comorbidity burden and direct healthcare costs associated with psoriatic arthritis (PsA). Adults (18-64 years) with ≥ 2 claims for a PsA diagnosis ≥ 30 days apart in the Truven Health MarketScan database (July 2009-June 2014) were selected as the case group. The index date was randomly selected after the first claim for PsA. Controls free of PsA and psoriasis (PsO) in their entire claims history were assigned the same index date and were matched with the cases on age, gender, and geographic region. All patients had ≥ 12 months of continuous eligibility before and after (study period) the index date. PsA-associated comorbidities, medication use, and medical service utilization were compared between matched groups using Wilcoxon signed rank and McNemar's tests. Costs were compared using multivariable generalized linear models. The 35,061 matched pairs had a mean age of 49.11 ± 10.20 years and 52.73% were female. During the study period, PsA patients had more PsA-associated comorbidities and significantly higher medication use than controls (all-cause medications 96.64 vs. 78.95%, p < 0.0001). PsA patients had significantly greater medical service use (inpatient admissions, hospitalization days, emergency room visits, outpatient services; all p < 0.0001) and higher annual direct healthcare costs per patient than controls (adjusted cost difference [ACD] = $18,482, including higher medical costs [ACD = $6440] and all-cause pharmacy costs [ACD = $11,737]; all p < 0.0001). Overall, PsA patients had a significantly higher PsA-related comorbidity burden, healthcare utilization, and direct healthcare costs than people free of PsA and PsO, underscoring the need for more effective treatments and improved care delivery systems.

Deriving common comorbidity indices from the MedDRA classification and exploring their performance on key outcomes in patients with rheumatoid arthritis

Objective

To develop algorithms for calculating the Rheumatic Diseases Comorbidity Index (RDCI), Charlson-Deyo Index (CDI) and Functional Comorbidity Index (FCI) from the Medical Dictionary for Regulatory Activities (MedDRA), and to assess how these MedDRA-derived indices predict clinical outcomes, utility and health resource utilization (HRU).

Methods

Two independent researchers linked the preferred terms of the MedDRA classification into the conditions included in the RDCI, the CDI and the FCI. Next, using data from the Norwegian Register-DMARD study (a register of patients with inflammatory joint diseases treated with DMARDs), the explanatory value of these indices was studied in models adjusted for age, gender and DAS28. Model fit statistics were compared in generalized estimating equation (prediction of outcome over time) models using as outcomes: modified HAQ, HAQ, physical and mental component summary of SF-36, SF6D and non-RA related HRU.

Results

Among 4126 patients with RA [72% female, mean (s.d.) age 56 (14) years], median (interquartile range) of RDCI at baseline was 0.0 (1.0) [range 0-6], CDI 0.0 (0.0) [0-7] and FCI 0.0 (1.0) [0-6]. All the comorbidity indices were associated with each outcome, and differences in their performance were moderate. The RDCI and FCI performed better on clinical outcomes: modified HAQ and HAQ, hospitalization, physical and mental component summary, and SF6D. Any non-RA related HRU was best predicted by RDCI followed by CDI.

Conclusion

An algorithm is now available to compute three commonly used comorbidity indices from MedDRA classification. Indices performed comparably well in predicting a variety of outcomes, with the CDI performing slightly worse when predicting outcomes reflecting functioning and health.

Cost and Cost Effectiveness of Treatments for Psoriatic Arthritis: A Systematic Literature Review

BACKGROUND

Psoriatic arthritis is a long-term inflammatory arthropathy occurring in a subgroup of patients with psoriasis. In addition to irreversible bone erosions, joint destruction, and skin manifestations, psoriatic arthritis is associated with numerous comorbid conditions. Over the last 5 years, new treatments emerged; the analysis and comparisons of their additional costs and the added benefits have become increasingly important to optimize the limited resources available.

METHODS

A systematic literature review covering PubMed, EMBASE, and the Cochrane Library was performed from May 2012 to October 2017 focusing on the most recent evidence of costs, benefits, and burden of psoriatic arthritis and its treatments. All economic evaluations assessing the burden of patients with psoriatic arthritis and written in English were eligible for inclusion. We also performed an assessment of the quality of the studies.

RESULTS

Of the 1652 references found in the literature search, nine cost-effectiveness analyses and 12 cost-of-illness studies were included in the current review. Patients with psoriatic arthritis incur substantially higher direct and indirect costs, as compared with patients with psoriasis without arthritis or patients with other inflammatory diseases. The cost of treatment with biologic therapies is the major predictor of the total cost. However, individuals with psoriatic arthritis are also affected by substantial productivity losses and indirect costs. Biologic therapies are generally cost effective vs. conventional therapies (e.g., synthetic drugs) for treating psoriatic arthritis.

CONCLUSIONS

Psoriatic arthritis is associated with a significant economic burden and biologic therapies contribute significantly to these costs. Biologic therapies are more effective than disease-modifying anti-rheumatic drugs for the symptoms and signs of psoriatic arthritis and for improving quality of life and inhibiting structural radiological damage. Therefore, biologic therapies are cost effective compared with conventional therapies: the increased direct cost associated with biologic drugs is offset by the significant improvement in the efficacy of treatments and in patient management of psoriatic arthritis.

Perfil de gastos com o tratamento da Artrite Reumatoide para pacientes do Sistema Único de Saúde em Minas Gerais, Brasil, de 2008 a 2013

Resumo A artrite reumatoide (AR) é uma doença crônica que afeta cerca de 1% da população adulta. No estudo de coorte histórica de pacientes de Minas Gerais, registrados no Sistema de Informações Ambulatoriais (SIA), em 2008-2013, foram identificados 11.573 indivíduos. A perspectiva foi a do financiador público e os valores observados como gastos do Sistema Único de Saúde (SUS) foram ajustados pelo Índice Nacional de Preços ao Consumidor Amplo (IPCA), de dezembro de 2015. O Etanercept foi o tratamento mais caro. A análise múltipla mostrou uma relação negativa entre o aumento das despesas e idade, sexo feminino e diagnóstico de entrada na coorte, e relação positiva para as variáveis Índice de Desenvolvimento Humano Municipal (IDH-M) e o uso de medicamentos bloqueadores do fator de necrose tumoral (ANTI-TNF). Este estudo identificou os fatores que têm impacto sobre o gasto com o tratamento medicamentoso da AR. Também apontou que métodos que permitem extrair dados demográficos e de gastos de sistemas de informação administrativos podem ser ferramentas importantes na construção de estudos econômicos capazes de subsidiar as avaliações econômicas de saúde, especialmente do ponto de vista da gestão.

Societal costs and patients' experience of health inequities before and after diagnosis of psoriatic arthritis: a Danish cohort study

OBJECTIVES

To comprehensively study the comorbidities, healthcare and public transfer (allowance) costs in patients with psoriatic arthritis (PsA) before and after diagnosis.

METHODS

Nationwide cohort study, using data from Danish registries from January 1998 through December 2014. A total of 10 525 patients with PsA and 20 777 matched general population comparator (GPC) subjects were included. Societal costs, employment status and occurrence of comorbidities in patients with PsA both before and after diagnosis were compared with GPC subjects.

RESULTS

At baseline, patients with PsA had significantly more comorbidities, including cardiovascular disease (OR 1^.70 95% CI 1^.55 to 1^.86), respiratory diseases (OR 1^.73 95% CI 1^.54 to 1^.96) and infectious diseases (OR 2^.03 95% CI 1^.69 to 2^.42) compared with GPC subjects. At all time points, patients with PsA had higher total healthcare and public transfer costs; they also had lower income (p<0.001) and incurred a net average increased societal cost of €10 641 per patient-year compared with GPC subjects following diagnosis. The relative risk (RR) for being on disability pension 5 years prior to PsA diagnosis was 1^.36 (95% CI 1^.24 to 1^.49) compared with GPC subjects. The RR increased to 1^.60 (95% CI 1^.49 to 1^.72) at the time of diagnosis and was 2^.69 (95% CI 2^.40 to 3^.02) 10 years after diagnosis, where 21^.8% of the patients with PsA received disability pension.

CONCLUSIONS

Our findings are suggestive of health inequity for patients with PsA and call for individual preventive measures and societal action.

Treatment patterns, complications, and direct medical costs associated with ankylosing spondylitis in Chinese urban patients: a retrospective claims dataset analysis

AIM

To describe treatment pattern, complications, and direct medical costs associated with ankylosing spondylitis (AS) in Chinese urban patients.

METHODS

The 2013 China Health Insurance Research Association (CHIRA) urban insurance claims database was used to identify patients with AS. The identified patients were stratified by AS treatments for the comparisons of well established AS-related complications and direct medical costs. Conventional regression analyses adjusted the collected patient baseline characteristics to confirm the impact of treatments on complications and direct medical costs.

RESULTS

Of the identified 1299 patients with AS, 18.0% received non-steroidal anti-inflammatory drugs (NSAID), 11.2% received immunosuppressant, 48.2% received NSAID plus immunosuppressant, 4.6% received biologic agents, and 17.9% received medications without indication for AS. Biologic group was associated with the lowest proportion of AS-related complications (8.3%) that was confirmed by multiple logistic regression analysis (odds ratio = 0.200, p = .017). The biologic group was also associated with highest direct medical costs (median: RMB = 14,539) that were confirmed by the multiple generalized linear model (coefficient = 1.644, p < .001).

CONCLUSIONS

Biologics were not commonly used for AS in Chinese patients likely due to their high cost. Future studies are needed to confirm the potential long-term clinical benefits associated biologic treatment for AS.

The economic impact of early retirement attributed to rheumatic diseases: results from a nationwide population-based epidemiologic study

OBJECTIVES

To measure early retirement due to self-reported rheumatic diseases (RDs) and to estimate the respective indirect costs and years of working life lost (YWLL).

METHODS

We used individual level data from the national, cross-sectional, population-based EpiReumaPt study (September 2011-December 2013) where 10,661 inhabitants were randomly surveyed in order to capture and characterize all cases of RD within a representative sample of the Portuguese population. In this analysis, we used all participants aged between 50 and 64 years, near the official retirement age. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. YWLL were estimated as the difference between each participant's current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. We also calculated the percentage of time in inactivity (inactivity ratio = YWLL/Active age-range [15-64 years old]).

RESULTS

29.9% of the Portuguese population with ages between 50 and 64 years were retired with 13.1% self-reporting retirement due to RD. The estimated annual indirect cost following premature retirement attributed to RD was €910 million (€555 per capita; €1625 per self-reported RD patient and €13,592 per early retiree due to RD). Females contributed with 84% for these costs (€766 million; €882 per capita vs €187 from males). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. RD patients with higher values of disability have the highest risk of early retirement.

CONCLUSIONS

Early retirement attributed to self-reported RD amounts to approximately 0.5% of the national gross domestic product (GDP) in 2013, due to large YWLL. Both the public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

Disease activity, quality of life and indirect costs of psoriatic arthritis in Poland

The aim of the study was to assess the indirect costs, health-related quality of life and clinical characteristics of patients with psoriatic arthritis (PsA), measured using a PsA disease activity index in Poland. Additionally, we aimed to investigate the association between the activity, utility of PsA-affected patients and productivity loss in a Polish setting. A questionnaire survey was conducted to assess disease activity, as well as productivity loss, and a paper version of the EuroQoly-5D-3L questionnaire was used to assess productivity loss and the quality of life. Indirect costs were assessed with the human capital approach employing the gross domestic product (GDP) per capita, gross value added (GVA) and gross income (GI) per worker in 2014 in Poland and were expressed in Polish zlotys (PLN) as well as in euros. The correlation was presented using the Spearman correlation coefficient. Our analysis was performed on the basis of 50 full questionnaires collected. We observed a mean utility value of 0.6567. The mean number of days off work was 2.88 days per month, and mean on-the-job productivity loss was 24.1 %. Average monthly indirect costs per patient were €206.7 (864.01 PLN) calculated using the GDP; €484.56 (2025.46 PLN) calculated using the GVA; and €209.70 (876.56 PLN) calculated using the GI. PsA reduces the patients' quality of life as well as their productivity loss associated with both absenteeism and presenteeism. Total indirect costs were negatively correlated with utility. The greater the disease activity, the lower the utility and the greater the indirect costs.

Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience

Patients with psoriatic arthritis (PsA) may not be optimally treated. The impact of the disease extends beyond skin and joint symptoms, impairing quality of life. This indicates that the adoption of a patient-focused approach to PsA management is necessary. An expert multidisciplinary working group was convened, with the objective of developing an informed perspective on current best practice and needs for the future management of PsA. Topics of discussion included the barriers to current best practice and calls to action for the improvement of three areas in PsA management: early and accurate diagnosis of PsA, management of disease progression and management of the impact of the condition on the patient. The working group agreed that, to make best use of the available of diagnostic tools, clinical care recommendations and effective treatments, there is a clear need for healthcare professionals from different disciplines to collaborate in the management of PsA. By facilitating appropriate and rapid referral, providing high quality information about PsA and its treatment to patients, and actively involving patients when choosing management plans and setting treatment goals, management of PsA can be improved. The perspective of the working group is presented here, with recommendations for the adoption of a multidisciplinary, patient-focused approach to the management of PsA.

Less educated and older patients have reduced access to biologic DMARDs even in a country with highly developed social welfare (Norway): results from Norwegian cohort study NOR-DMARD

OBJECTIVE

To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA.

METHODS

Data from the Norwegian Register of DMARDs collected between 2000 and 2012 were used. Only DMARD-naïve patients with RA starting their first conventional synthetic DMARD were included in the analyses. The start of the first bDMARD was the main outcome of interest. Cox regression analyses were used to explore the impact of education, age and gender on the start of a first bDMARD, adjusting for confounders, either at baseline or varying over time (time-varying model).

RESULTS

Of 1946 eligible patients [mean (s.d.) age: 55 (14) years, 68% females], 368 (19%) received a bDMARD during follow-up (mean 2.6 years). In the baseline prediction model, older age [Hazard Ratio (HR) 0.97, 95% CI: 0.96, 0.98], lower education [HR = 0.76 and 0.68 for low and intermediate education levels vs college/university education, respectively (P = 0.01)] and female gender [only in the period 2000-03, HR = 0.61 (95% CI: 0.41, 0.91)] were associated with a lower hazard ratio to start a bDMARD. The time-varying model provided overall consistent results, but the effect of education was only relevant for older patients (>57 years) and became more pronounced by the end of the decade.

CONCLUSIONS

Less educated and older patients have disadvantages with regard to access to costly treatments, even in a country with highly developed welfare like Norway. Females had lower access in the beginning of the 2000s, but access had improved by the end of the decade.

Incremental Costs for Psoriasis and Psoriatic Arthritis in a Population-based Cohort in Southern Sweden: Is It All Psoriasis-attributable Morbidity?

Objective.

To estimate incremental costs for patients with psoriasis/psoriatic arthritis (PsO/PsA) compared to population-based referents free from PsO/PsA and estimate costs attributable specifically to PsO/PsA.

Methods.

Patients were identified by International Classification of Diseases, 10th ed., codes for PsO/PsA using information from 1998 to 2007 in the Skåne Healthcare Register, covering healthcare use for the population of the Skåne region of Sweden. For each patient, 3 population-based referents were selected. Data were retrieved from Swedish registers on healthcare, drugs, and productivity loss. The human capital method was used to value productivity losses. Mean annual costs for 2008 to 2011 were assessed from a societal perspective.

Results.

We identified 15,283 patients fulfilling the inclusion criteria for PsO [n = 12,562, 50% women, mean age (SD) 52 (21) yrs] or PsA [n = 2721, 56% women, mean age 54 (16) yrs] and included 45,849 referents. Mean annual cost per patient with PsO/PsA was 55% higher compared to referents: €10,500 vs €6700. The cost was 97% higher for PsA compared to PsO. Costs due to productivity losses represented the largest share of total costs, ranging from 52% for PsO to 60% for PsA. Biological drug costs represented 10% of the costs for PsA and 1.6% for PsO. The proportion of cost identified as attributable to PsO/PsA problems was greatest among the patients with PsA (drug costs 71% and healthcare costs 31%).

Conclusion.

Annual mean incremental societal cost per patient was highest for PsA, mainly because of productivity losses and biological treatment. A minor fraction of the costs were identified as attributable to PsO/PsA specifically, indicating an increased morbidity in these patients that needs to be further investigated.

Cost of arthritis: a systematic review of methodologies used for direct costs

A substantial amount of healthcare and costs are attributable to arthritis, which is a very common chronic disease. This paper presents the results of a systematic review of arthritis cost studies published from 2008 to 2013. MEDLINE, Embase, EconLit databases were searched, as well as governmental and nongovernmental organization websites. Seventy-one reports met the inclusion/exclusion criteria, and 24 studies were included in the review. Among these studies, common methods included the use of individual-level data, bottom-up costing approach, use of both an arthritis group and a control group to enable incremental cost computation of the disease, and use of regression methods such as generalized linear models and ordinary least squares regression to control for confounding variables. Estimates of the healthcare cost of arthritis varied considerably across the studies depending on the study methods, the form of arthritis and the population studied. In the USA, for example, the estimated healthcare cost of arthritis ranged from $1862 to $14,021 per person, per year. The reviewed study methods have strengths, weaknesses and potential improvements in relation to estimating the cost of disease, which are outlined in this paper. Caution must be exercised when these methods are applied to cost estimation and monitoring of the economic burden of arthritis.

Indirect costs of rheumatoid arthritis

It is estimated that in Poland about 400,000 persons in general suffer from inflammatory joint diseases, including rheumatoid arthritis (RA). Epidemiological surveys documenting the frequency and disturbance of musculoskeletal disorders in the Polish population are few in number. Most of the estimations are based on epidemiological data from other countries (prevalence of 0.5-1%). According to the data of the National Health Fund in Poland 135,000-157,000 persons in total are treated because of rheumatoid arthritis per year [ICD10 (International Statistical Classification of Diseases and Related Health Problems): M05, M06]. In the case of this group of diseases indirect costs significantly outweigh the direct costs. Indirect costs increase together with activity level of the disease. The cost analysis of productivity loss of RA patients indicates that sickness absenteeism and informal care are the most burdensome. At the national level it amounts in total from 1.2 billion to 2.8 billion PLN per year, depending on the method of analysis. These costs could be significantly reduced through early diagnosis and introduction of effective treatment.

Consensus Decision Models for Biologics in Rheumatoid and Psoriatic Arthritis: Recommendations of a Multidisciplinary Working Party

Introduction

Biologic therapies are efficacious but costly. A number of health economic models have been developed to determine the most cost-effective way of using them in the treatment pathway. These models have produced conflicting results, driven by differences in assumptions, model structure, and data, which undermine the credibility of funding decisions based on modeling studies. A Consensus Working Party met to discuss recommendations and approaches for future models of biologic therapies.

Methods

Our working party consisted of clinical specialists, modelers, and policy makers. Two 1-day meetings were held for members to arrive at consensus positions on model structure, assumptions, and appropriate data sources. These views were guided by clinical aspects of rheumatoid and psoriatic arthritis and the principles of evidence-based medicine. Where opinions differed, we sought to identify a research agenda that would generate the evidence needed to reach consensus.

Results

We gained consensus in four areas of model development: initial response to treatment; long-term disease progression; lifetime costs and benefits; and model structure. Consensus was also achieved on some key parameters such as choices of outcome measures, methods for extrapolation beyond trial data, and treatment switching. A research agenda to support further consensus was also identified.

Conclusion

Consensus guidance that fully reflects current evidence and clinical understanding was gained successfully. In addition, research needs have been identified. Such guidance can be updated as evidence develops and policy questions change and need not be prescriptive as long as deviations from consensus are clearly explained and justified.

Funding

Arthritis Research UK and the UK Medical Research Council Network of Hubs for Trials Methodology Research.

Electronic supplementary material

The online version of this article (doi:10.1007/s40744-015-0020-0) contains supplementary material, which is available to authorized users.

Counting Costs under Severe Financial Constraints: A Cost-of-Illness Analysis of Spondyloarthropathies in a Tertiary Hospital in Greece

Objective.

To investigate the total annual direct cost of patients with spondyloarthritis (SpA) in Greece.

Methods.

Retrospective study with 156 patients diagnosed and followed up in the rheumatology clinic of the University Hospital of Ioannina. Sixty-four had ankylosing spondylitis (AS) and 92 had psoriatic arthritis (PsA). Health resource use for each patient was elicited through a retrospective chart review that documented the use of monitoring visits, medications, laboratory/diagnostic tests, and inpatient stays for the previous year from the date that the review took place. Costs were calculated from a third-party payer perspective and are reported in 2014 euros.

Results.

The mean ± SD annual direct cost for the patients with SpA reached €8680 ± 6627. For the patients with PsA and AS, the cost was estimated to be €8097 ± 6802 and €9531 ± 6322, respectively. The major cost was medication, which represented 88.9%, 88.2%, and 89.3% of the mean total direct cost for SpA, AS, and PsA, respectively. The annual amount of the scheduled tests for all patients corresponded to 7.5%, and for those performed on an emergency basis, 1.1%. Further, the cost for scheduled and emergency hospitalization, as well as the cost of scheduled visits to an outpatient clinic, corresponded to 2.5% of the mean total annual direct cost for the patients with SpA.

Conclusion.

SpA carries substantial financial cost, especially in the era of new treatment options. Adequate access and treatment for patients with SpA remains a necessity, even in times of fiscal constraint. Thus, the recommendations of the international scientific organizations should be considered when administering high-cost drugs such as biological treatments.

Direct and indirect costs associated with ankylosing spondylitis and related disease activity scores in Turkey

This study assessed quality of life, direct and indirect healthcare costs related to ankylosing spondylitis (AS). This study included 650 prevalent AS patients visiting seven centers at tertiary healthcare institutions in Turkey who were interviewed using a standard questionnaire to determine annual direct and indirect healthcare costs. Eligible patients were age ≥18 years with AS for at least 12 months. Direct costs were categorized as inpatient, outpatient and pharmacy, and AS-related consultation. Indirect costs were categorized as workday loss, additional AS-related costs, and caregiver costs. Clinical outcome measures were obtained, including Patients’ Global Disease Activity (Pt-GDA); visual analog scale (Pain-VAS) for pain; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Functional Index (BASFI), and Metrology Index (BASMI) scores, and EuroQoL 5 dimension (EQ-5D) health status survey scores. Mean (€4,335.20) and median (€5,671.00) annual costs per patient were calculated. Pharmacy costs (€4,032.73) were highest among overall expenditures, followed by additional AS-related consultation (€2,480.38), outpatient (€225.02), and inpatient costs (€29.98). Over half of AS patients (54.8 %) experienced work loss. Related average annual costs were €414.16, based on income level. 10.3 % of AS patients incurred an additional €2,008.07 in 1 year. 6.8 % of patients required caregivers and incurred €778.70 in average annual patient paid costs. Mean Pt-GDA, Pain-VAS, EQ-5D, BASDAI, BASFI, and BASMI scores were 4.4, 40.5, 62.7, 3.6, 3.1, and 2.9, respectively. Direct and indirect AS-related costs are high and represent a considerable economic burden on Turkish AS patients.

How much of the productivity losses among psoriasis patients are due to psoriasis

BACKGROUND

In previous studies, productivity losses have been measured specifically due to psoriasis or generally due to health problems in psoriasis patients. There is no information on the proportion of health related productivity losses that are due to psoriasis. The aim of this study was to estimate the proportion of productivity losses due to psoriasis and due to other medical problems among employed psoriasis patients.

METHODS

Patients visiting a tertiary level dermatological clinic during a one-year period due to psoriasis or psoriasis arthritis, who were employed, were selected to the study. A questionnaire was used to assess productivity losses during the previous month.

RESULTS

Psoriasis accounted for 38% of the total lost productivity costs. One fifth of patients had been on sick leave (absenteeism) due to psoriasis and a third of patients worked despite being sick with psoriasis (presenteeism). Men had higher costs of presenteeism, but the costs of absenteeism due to psoriasis were lower for men than for women.

CONCLUSIONS

Productivity losses should be assessed disease specifically to avoid overestimations of the role of the disease on indirect costs. Our study shows that about a third of the lost productivity costs are due to psoriasis.

Cost-effectiveness of TNF inhibitors vs synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a Markov model study based on two longitudinal observational studies

Objective. The objective of this study was to estimate the additional costs and health benefits of adding a TNF inhibitor (TNFi) (adalimumab, certolizumab, etanercept, golimumab, infliximab) to a synthetic DMARD (sDMARD), e.g. MTX, in patients with RA.

Methods. We developed the Norwegian RA model as a Markov model simulating 10 years of treatment with either TNFi plus sDMARDs (TNFi strategy) or sDMARDs alone (synthetic strategy). Patients in both strategies started in one of seven health states, based on the Short Form-6 Dimensions (SF-6D). The patients could move to better or worse health states according to transition probabilities. In the TNFi strategy, patients could stay on TNFi (including switch of TNFi), or switch to non-TNFi-biologics (abatacept, rituximab, tocilizumab), sDMARDs or no DMARD. In the synthetic strategy, patients remained on sDMARDs. Data from two observational studies were used for the assessment of resource use and utilities in the health states. Health benefits were evaluated using the EuroQol-5 Dimensions (EQ-5D) and SF-6D.

Results. The Norwegian RA model predicted that 10-year discounted health care costs totalled €124 942 (€475 266 including production losses) for the TNFi strategy and €65 584 (€436 517) for the synthetic strategy. The cost per additionally gained quality-adjusted life-year of adding a TNFi was €92 557 (€60 227 including production losses) using SF-6D and €61 285 (€39 841) using EQ-5D. Including health care costs only, the probability that TNFi treatment was cost-effective was 90% when using EQ-5D, assuming a Norwegian willingness-to-pay level of €67 300.

Conclusion. TNFi treatment for RA is cost-effective when accounting for production losses. Excluding production losses, TNFi treatment is cost-effective using EQ-5D, but not SF-6D.

Dose modification of anti-TNF in rheumatoid arthritis and estimated economical impact: a review of observational studies

Anti-TNF drugs indicated for the treatment of moderate-to-severe active rheumatoid arthritis (RA) presents similar efficacy, safety and potential toxicity profiles, with more than 10 years' treatment experience. Several pharmacoeconomic evaluations had demonstrated their favorable cost-effectiveness profile in RA patients, based on pivotal clinical studies data from different countries and perspectives. However, in clinical practice, individual profiles of patients and drugs leads to dose modifications that may be associated with substantial cost deviations. Here, we further discuss the effect of dose titration of these biological drugs in clinical practice over their RA cost-effectiveness profiles.

The burden of disease in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease which, if left untreated, leads to functional disability, pain, reduced health-related quality of life and premature mortality. Between 0.5% and 1% of the population are affected worldwide, and between 25 and 50 new cases evolve in a population of 100,000. Practically all patients with RA require initiation with disease-modifying antirheumatic treatment to retard or stop progression, control disease manifestations and reduce the disease burden. If disease course is monitored with adjustment of medication, lifestyle factors, and exercise, as well as physical activity levels, co-morbidities may be prevented in the course of RA. During the last decade, major progress has been made in treating RA through early identification and treatment of the disease. Many patients still experience premature work disability and co-morbidities. For societies, the economic burden of RA is high in terms of direct and indirect costs, including modern drug treatment.

Work productivity loss and fatigue in psoriatic arthritis

OBJECTIVE

To explore the relationship between fatigue and work productivity loss (WPL) in people with psoriatic arthritis (PsA).

METHODS

Data were collected from participants in the Utah Psoriasis Initiative Arthritis registry between January 2010 and May 2013. WPL was measured with the 8-item Work Limitations Questionnaire. Fatigue was assessed with question 1 from the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI#1), "How would you describe the overall level of fatigue/tiredness you have experienced?" and with question 1 from the Psoriatic Arthritis Quality of Life Questionnaire (PsAQOL#1) "I feel tired whatever I do." Psoriatic activity was evaluated with tender joint count (TJC), swollen joint count (SJC), dactylitis count, enthesitis count, inflammatory back pain (IBP), physician global assessment, body surface area, and psoriasis pain and itch.

RESULTS

Among 107 participants, work productivity was reduced by 6.7%, compared to benchmark employees without limitations. Fatigue was reported by 54 patients (50.5%) on PsAQOL#1, and 64 (60.0%) were classified as high fatigue by BASDAI#1. TJC, SJC, enthesitis count, IBP, and depressed mood were highest or most frequent in participants reporting fatigue. After adjustments for psoriatic activity and depressed mood, WPL was associated with fatigue, as measured by PsAQOL#1 (p = 0.01) and BASDAI#1 (p = 0.002).

CONCLUSION

WPL was associated with fatigue, and the association was not entirely explained by the evaluated musculoskeletal, cutaneous, or psychiatric manifestations of PsA.

Remission in rheumatoid arthritis: benefit over low disease activity in patient-reported outcomes and costs

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes a considerable burden for the patient and society. It is not clear yet whether aiming for remission (REM) is worthwhile, especially when compared with low disease activity (LDA).

Methods

In 356 consecutive RA patients, we obtained data on physical function (health assessment questionnaire (HAQ)), health-related quality of life (HRQoL: Short Form 36 (SF36), Short Form 6 dimensions (SF-6D), Euro QoL 5D (EQ-5D)), work productivity (work productivity and activity impairment questionnaire (WPAI)), as well as estimation of direct and indirect costs. Cross-sectionally, data were compared in patients within different levels of disease activity according to the simplified disease activity index (SDAI; remission (REM ≤3.3); n = 87; low disease activity (LDA: 3.3 < SDAI ≤11); n = 103; moderate to high disease activity (MDA/HDA) >11 n = 119) by using analyses of variance (ANOVA). Longitudinal investigations assessed patients who changed from LDA to REM and vice versa.

Results

We found differences in patients achieving REM compared with LDA for HAQ (0.39 ± 0.58 versus 0.72 ± 68), WPAI (percentage impairment while working 11.8% ± 18.7% versus 26.8% ± 23.9%; percentage of overall activity impairment, 10.8% ± 14.1% versus 29.0% ± 23.6%)), EQ-5D (0.89 ± 0.12 versus 0.78 ± 0.6) and SF-36 (physical component score (PCS): 46.0 ± 8.6 versus 38.3 ± 10.5; mental component score (MCS): 49.9 ± 11.1 versus 47.9 ± 12.3) (P < 0.01 for all, except for SF36 MCS). Regarding costs, we found significant differences of direct and indirect costs (P < 0.05) within different levels of disease activity, with higher costs in patients with higher states of disease activity. Longitudinal evaluations confirmed the main analyses.

Conclusion

Patients with REM show better function, HRQoL, and productivity, even when compared with another good state, such as LDA. Also from a cost perspective, REM appears superior to all other states.

Evolution of cost structures in rheumatoid arthritis over the past decade

Objective

To estimate the changes in direct and indirect costs induced by patients with rheumatoid arthritis (RA) in German rheumatology, between 2002 and 2011. To examine the impact of functional status on various cost domains. To compare the direct costs incurred by patients at working age (18–64 years) to patients at an age of retirement (≥65 years).

Methods

We analysed data from the National Database of the German Collaborative Arthritis Centres with about 3400 patients each year. Costs were calculated using fixed prices as well as annually updated cost factors. Indirect costs were calculated using the human capital as well as the friction cost approaches.

Results

There was a considerable increase in direct costs: from €4914 to €8206 in patients aged 18–64, and from €4100 to €6221 in those aged ≥65, attributable to increasing prescription of biologic agents (18–64 years from 5.6% to 31.2%, ≥65 years from 2.8% to 19.2%). This was accompanied by decreasing inpatient treatment expenses and indirect costs due to sick leave and work disability. The total growth of cost, on average, was €2437–2981 for patients at working age, and €2121 for patients at retirement age.

Conclusions

The increase in treatment costs for RA over the last decade was associated with lower hospitalisation rates, better functional status and a lower incidence of work disability, offsetting a large proportion of risen drug costs. Since the rise in drug costs has manifested a plateau from 2009 onwards, no relevant further increase in total costs for patients with RA treated in German rheumatology is expected.