Cost of illness studies in rheumatic diseases

Insight into the Epidemiology of the Adult-onset Systemic Autoimmune Rheumatic Diseases in Egypt: A Descriptive Study of 8690 Patients

BACKGROUND/OBJECTIVE

Although systemic autoimmune rheumatic diseases (SARDs) seem to be ubiquitous, Africa and the Middle East seem to be a remarkable exception with scarcity of data compared with the developed countries. Furthermore, most of the studies addressed a particular disease. This work aimed to shed light on the relative frequency and epidemiology of the different adult-onset SARDs in Egypt.

METHODS

This is a retrospective hospital-based study including six university hospitals providing free health care services: Cairo, Alexandria, Tanta, Suez Canal, Beni-Suef and Assiut University Hospitals. All available files for patients attending the outpatient clinics or admitted to the inpatient departments between January 2000 and December 2021 were retrospectively reviewed. Data about the patient's diagnosis, gender, age at disease onset, year of disease onset and residence were collected.

RESULTS

The study included 8690 patients. Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Behçet's disease (BD) and spondyloarthropathies (SPA) represented the main SARDs in Egypt. They mainly affect young patients below the age of 40 years. RA and SLE mainly affect females; males are mainly affected by axial SPA and BD. There is an increasing incidence of SARDs during the study period.

CONCLUSION

The study revealed the high burden of SARDs in Egypt, helping better allocation of economic resources for the management of diseases of the highest prevalence and those affecting the young reproductive age groups. Increased public and medical staff awareness about SARDs is recommended to help early referral of patients to rheumatologists and, hence, better estimation of their epidemiology.

Ceramides in Autoimmune Rheumatic Diseases: Existing Evidence and Therapeutic Considerations for Diet as an Anticeramide Treatment

Autoimmune rheumatic diseases (AIRDs) constitute a set of connective tissue disorders and dysfunctions with akin clinical manifestations and autoantibody responses. AIRD treatment is based on a comprehensive approach, with the primary aim being achieving and attaining disease remission, through the control of inflammation. AIRD therapies have a low target specificity, and this usually propels metabolic disturbances, dyslipidemias and increased cardiovascular risk. Ceramides are implicated in inflammation through several different pathways, many of which sometimes intersect. They serve as signaling molecules for apoptosis, altering immune response and driving endothelial dysfunction and as regulators in the production of other molecules, including sphingosine 1-phosphate (S1P) and ceramide 1-phosphate (C1P). With lipid metabolism being severely altered in AIRD pathology, several studies show that the concentration and variety of ceramides in human tissues is altered in patients with rheumatic diseases compared to controls. As a result, many in vitro and some in vivo (animal) studies research the potential use of ceramides as therapeutic targets in rheumatoid arthritis (RA), ankylosing spondylitis, systemic lupus erythematosus, fibromyalgia syndrome, primary Sjögren's syndrome, systemic sclerosis, myositis, systemic vasculitis and psoriatic arthritis. Furthermore, the majority of ceramide synthesis is diet-centric and, as a result, dietary interventions may alter ceramide concentrations in the blood and affect health. Subsequently, more recently several clinical trials evaluated the possibility of distinct dietary patterns and nutrients to act as anti-ceramide regimes in humans. With nutrition being an important component of AIRD-related complications, the present review details the evidence regarding ceramide levels in patients with AIRDs, the results of anti-ceramide treatments and discusses the possibility of using medical nutritional therapy as a complementary anti-ceramide treatment in rheumatic disease.

A systematic review on time trend incidence of rheumatoid arthritis in outpatient rheumatology clinics

Objectives

To classify patients with rheumatoid arthritis (RA) in an earlier stage of the disease, the ACR/EULAR classification criteria were updated in 2010. These criteria might have led to an increased incidence of RA in the rheumatology clinic. Since a higher incidence increases the socio-economic burden of RA, it is worthwhile to evaluate whether there is a time effect.

Materials and methods

A systematic review was conducted using Embase, Medline Ovid, Cochrane Central, and Web of Science from database inception to February 2021. Included were only articles that addressed incidence rates of rheumatoid arthritis from rheumatology outpatient clinics.

Results

Of the 6,289 publications only 243 publications on RA were found eligible for full-text review. Nine studies were included reporting incidence. The pooled incidence for RA was 11% (95% CI 6-16%) per year. Over time the incidence increased after the introduction of the 2010 ACR/EULAR classification criteria. Overall there was a high intragroup heterogeneity (I 2 = 97.93%, p < 0.001), caused by geographical area, study design and differences in case definitions.

Conclusion

Although the incidence seems to increase after the introduction of the 2010 ACR/EULAR criteria, no conclusions can be drawn on this time effect due to heterogeneity.

Progress towards universal health coverage in the context of rheumatic diseases in India

AIM

This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India.

METHOD

The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self-reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection.

RESULTS

3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE-10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8-11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE-10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India.

CONCLUSION

Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.

The impact of osteoarthritis on early exit from work: results from a population-based study

Background

Osteoarthritis (OA) is a leading cause of pain and disability, which may be a source of productivity losses. The objectives of this study were to describe the impact of OA, namely through pain and physical disability, on early exit from work and to calculate its economic burden.

Methods

We analysed data from the national, cross-sectional, population-based EpiReumaPt study (Sep2011–Dec2013) in which 10,661 individuals were randomly surveyed in order to capture all cases of rheumatic diseases. We used all participants aged 50–64, near the official retirement age, who were clinically validated by experienced rheumatologists (n = 1286), including OA cases. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. The impact of OA on the likelihood of early exit from work and the population attributable fractions used to calculate due economic burden (indirect costs) were obtained at the individual level by logistic regression. All results were based on weighted data.

Results

Almost one third of the Portuguese population aged 50–64 had OA (29.7%; men: 16.2% and women: 43.5%) and more than half were out of paid work (51.8%). Only knee OA is associated with early exit from work (OR: 2.25; 95%CI: 1.42–3.59; p = 0.001), whereas other OA locations did not reach any statistical difference. Furthermore, we observed an association between self-reported longstanding musculoskeletal pain (OR: 1.55; 95%CI: 1.07–2.23; p = 0.02) and pain interference (OR: 1.35; 95%CI: 1.13–1.62; p = 0.001) with early exit from work. We also detected a clear relationship between levels of disability, measured by the Health Assessment Questionnaire (HAQ), and the probability of work withdrawal. The estimated annual cost of early exit from work attributable to OA was €656 million (€384 per capita; €1294 per OA patient and €2095 per OA patient out-of-work).

Conclusions

In this study, we observed an association between OA and early exit from work, largely dependent on pain and disability. This relationship translates into a meaningful economic burden amounting to approximately 0.4% of the national Gross Domestic Product (GDP). The high prevalence and the impact of this disabling chronic disease highlight the need to prioritize policies targeting early exit from work in OA.

Quality of Care in Rheumatoid Disease from the Clinician Perspective: A Modified Delphi Panel Approach

INTRODUCTION

To establish clinical consensus on important and relevant quality-of-care (QoC) attributes in rheumatic disease (RD) treatment that may improve treatment outcomes and guide best practices.

METHODS

Twenty-three QoC attributes were identified in a literature review. Fifteen European-based clinicians were selected based on their contributions to RD guidelines, publications, and patient care. A three-round (an interview round and two web-based rounds) modified Delphi panel was conducted to reach consensus and finalize a QoC attribute list.

RESULTS

In round 1 (clinician interviews), clinicians reported 52 unique QoC attributes across 14 themes, with the greatest number of attributes reported in the "treatment goals" (n = 7) and "remote monitoring" (n = 7) themes. During rounds 2 and 3, the critically important QoC attributes most frequently reported were access to care/treatment (n = 14, 93.3%), safety of treatment (round 2 n = 14, 93.3%, round 3 n = 13, 86.7%), and access to clinicians and specialists (round 2: n = 13, 86.7%, round 3: n = 14, 93.3%). The final list contained 53 QoC attributes.

CONCLUSION

The study demonstrates consensus across several themes of QoC. Quality of care is a complex, multidimensional, and fluid concept that can be improved by ensuring patients have access to care, open communication between patients and clinicians, and the use of novel strategies, such as remote monitoring. Utilization of the attribute list can potentially improve the lives of patients, provide clinicians with tools to provide greater QoC, and improve the healthcare system as a whole.

FUNDING

Merck & Co., Inc.

Identifying heavy health care users among primary care patients with chronic non-cancer pain

Objective: The objective of this study was to identify biopsychosocial factors predicting primary care chronic non-cancer pain (CNCP) patients' risk of being heavy health care users. Methods: Patients reporting moderate to severe CNCP for at least 6 months with an active analgesic prescription from a primary care physician were recruited in community pharmacies. Recruited patients completed questionnaires documenting biopsychosocial characteristics. Using administrative databases, direct costs were estimated for health care services used by each patient in the year preceding and following the recruitment. Heavy health care users were defined as patients in the highest annual direct health care costs quartile. Logistic multivariate regression models using the Akaike information criterion were developed to identify predictors of heavy health care use. Results: The median annual direct health care cost incurred by heavy health care users (n = 63) was CAD (Canadian dollars) 7627, versus CAD 1554 for standard health care users (n = 188). The final predictive model of the risks of being a heavy health care user included pain located in the lower body (odds ratio [OR] = 3.03; 95% confidence interval [CI], 1.20-7.65), pain-related disability (OR = 1.24; 95% CI, 1.03-1.48), and health care costs incurred in the year prior to recruitment (OR = 17.67; 95% CI, 7.90-39.48). Variables in the model also included sex, comorbidity, patients' depression level, and attitudes toward medical pain cure. Conclusion: Patients suffering from CNCP in the lower body and showing greater disability were more likely to be heavy health care users, even after adjusting for previous-year direct health care costs. Improving pain management for these patients could have positive impacts on health care use and costs.

Correlations Between Sagittal Spinal Balance and Quality of Life in Rheumatoid Arthritis

STUDY DESIGN

Prospective study.

OBJECTIVE

To identify relationships between spinopelvic parameters and health-related quality of life in rheumatoid arthritis (RA).

SUMMARY OF BACKGROUND DATA

Little data are available on relationships between sagittal spinopelvic parameters and health-related quality of life in RA.

MATERIALS AND METHODS

The study and control groups comprised 120 RA patients and 60 controls. All subjects underwent anteroposterior and lateral radiography of the whole spine, including hip joints, and all completed clinical questionnaires. The radiographic parameters examined were: sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, C7/sacrofemoral distance ratio (C7/SFD), and spinosacral angle (SSA). Quality of life was assessed using a Visual Analog Scale for back pain, the Oswestry disability index questionnaire, and the Scoliosis Research Society (SRS-22) questionnaire. Statistical analysis was performed to identify significant differences between the study and control groups. In addition, correlations between radiologic parameters and clinical questionnaires were sought.

RESULTS

The patients and controls were found to be significantly different in terms of sacral slope, pelvic tilt, lumbar lordosis, thoracic kyphosis, C7/SFD, and SSA, but not for pelvic incidence (P>0.05). Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. Multiple regression analysis was performed to identify predictors of clinical outcome, and the results obtained revealed that C7/SFD significantly predicted Visual Analog Scale score and SSA predicted Oswestry disability index and SRS-22 scores.

CONCLUSIONS

Sagittal spinopelvic parameters were found to be significantly different in RA patients and normal controls. Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. In particular, C7/SFD and SSA were found to be significant predictors of clinical outcomes in RA.

Economic impact of lower-limb osteoarthritis worldwide: a systematic review of cost-of-illness studies

OBJECTIVE

An overview of the economic consequences - overall costs as well as cost breakdown (direct and indirect) - of hip and knee osteoarthritis (OA) worldwide.

METHODS

A systematic literature search of EMBASE, MEDLINE, Scopus and Cochrane databases for articles was performed independently by two rheumatologists who used the same predefined eligible criteria. Papers without abstracts and in languages other than English or French were excluded. Extracted costs were converted to an annual cost and to 2013 euros (€) by using the Consumer Price Index of the relevant countries and the 2013 Purchasing Power Parities between these countries and the European Union average.

RESULTS

A total of 45 abstracts were selected, and 32 articles were considered for the review. The studied populations were heterogeneous: administrative, hospital and national health survey data. Annual total costs per patient ranged from 0.7 to 12 k€, direct costs per patient from 0.5 to 10.9 k€ and indirect costs per patient from 0.2 to 12.3 k€. The weighted average annual costs per patient living with knee and hip OA were 11.1, 9.5 and 4.4 k€ for total, direct and indirect costs, respectively.

CONCLUSIONS

This review highlights the heterogeneity of studies and lack of methodologic consensus to obtain reliable cost-of-illness estimates for lower-limb OA. However, costs induced by the disease seem substantial and deserve to be more extensively explored.

Vertebral fractures affect functional status in postmenopausal rheumatoid arthritis patients

Functional disability is a major concern in patients with rheumatoid arthritis (RA). This retrospective study investigated the risk factors for vertebral fractures (VFs) in postmenopausal RA patients and determined the impact of VFs on functional status. Data from a cohort of 200 postmenopausal RA patients in a single hospital registry were analyzed. Demographic and clinical data, imaging data from spine radiographs, and bone mineral density (BMD) data were collected from the patients at baseline and at the final visit (a mean of 2.9 years after the first visit). Risk factors for incident VFs and their impact on the modified health assessment questionnaire (mHAQ) were analyzed. Twenty-eight patients (14%) developed new VFs (NVFs). Logistic regression analysis adjusted for age, BMI, and disease duration revealed that daily dose of prednisolone, femoral neck BMD, use of active vitamin D3, and use of a bisphosphonate at baseline were factors associated with NVF, with odds ratios (95% confidence interval) of 1.27 (1.05-1.54), 0.94 (0.91-0.97), 0.34 (0.13-0.89), and 0.31 (0.12-0.82), respectively. Patients with NVF exhibited worse mHAQ scores and a greater increase in mHAQ scores from baseline compared with those without NVF. In conclusion, incident VFs were associated with reduced functional status in postmenopausal patients with RA. It is important to prevent VFs to maintain the functional status of RA patients.

Bisphosphonates for the prevention and treatment of osteoporosis in patients with rheumatic diseases: a systematic review and meta-analysis

Background

While bisphosphonates (BPs) are commonly used in clinical treatment for osteoporosis, their roles on osteoporosis treatment for rheumatic patients remain unclear. We performed a meta-analysis to evaluate the efficacy of BPs on fractures prevention and bone mass preserving in rheumatic patients.

Methodology/Principal Findings

We searched PubMed, EmBase, and the Cochrane Central Register of Controlled Trials for relevant literatures with a time limit of Jan. 6, 2012. All randomized clinical trials of BPs for adult rheumatic patients with a follow-up of 6 months or more were included. We calculated relative risks (RRs) for fractures and weighted mean difference (WMD) for percent change of bone mineral density (BMD). Twenty trials were included for analysis. The RR in rheumatic patients treated with BPs was 0.61 (95%CI [0.44, 0.83], P = 0.002) for vertebral fractures, and 0.49 (95%CI [0.23, 1.02], P = 0.06) for non-vertebral fractures. The WMD of BMD change in the lumbar spine was 3.72% (95%CI [2.72, 4.72], P<0.001) at 6 months, 3.67% (95%CI [2.84, 4.50], P<0.001) at 12 months, 3.64% (95%CI [2.59, 4.69], P<0.001) at 24 months, and 5.87% (95%CI [4.59, 7.15], P<0.001) at 36 months in patients using BPs, as compared with those treated with calcium, vitamin D or calcitonin. In subgroup analyses, rheumatic patients using BPs for osteoporosis prevention had greater WMD than those using BPs for treating osteoporosis at 6 months (4.53% vs. 2.73%, P = 0.05) and 12 months (4.93% vs. 2.91%, P = 0.01).

Conclusions/Significance

In both short-term and middle-term, BPs can preserve bone mass and reduce the incidence of vertebral fractures in rheumatic patients, mainly for those who have GC consumption. The efficacy of BPs is better when using BPs to prevent rather than to treat osteoporosis in rheumatic patients.

Management of work disability in rheumatic conditions: a review of non-pharmacological interventions

Because of its substantial personal social and economic costs, workforce participation among individuals with rheumatic diseases has received considerable research attention. This chapter reviews non-pharmacological employment interventions for people with rheumatic diseases, focussing on the comprehensiveness of interventions, whether they have been targeted to those groups identified as most at risk, and intervention outcomes and effectiveness. Findings highlight that early diagnosis and treatment of rheumatic diseases may not be enough to keep individuals employed and that comprehensive work interventions may have positive psychological effects, as well as result in increased work participation. However, we lack data addressing the optimum time to intervene and subgroup analyses to determine whether some groups are at increased risk for poor work outcomes. Consistent inclusion of behavioural and psychological outcomes to evaluate interventions and compare studies is also needed, along with cost-benefit studies, to determine the long-term feasibility of work interventions.

Analysis of direct medical and nonmedical costs for care of rheumatoid arthritis patients using the large cohort database, IORRA

OBJECTIVES

Our goal was to determine the annual direct medical and nonmedical costs for the care of patients with rheumatoid arthritis (RA) using data from a large cohort database in Japan.

METHODS

Direct medical costs [out of pocket to hospitals and pharmacies and for complementary and alternative medicine (CAM)] and nonmedical costs (caregiving, transportation, self-help devices, house modifications) were determined for RA patients who were participants in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) studies conducted in October 2007 and April 2008. Correlations between these costs and RA disease activity, disability level, and quality of life (QOL) were assessed.

RESULTS

Data were analyzed from 5,204 and 5,265 RA patients in October 2007 and April 2008, respectively. The annual direct medical costs were JPY132,000 [out of pocket to hospital (US$1 = JPY90 in 2007)], JPY84,000 (out of pocket to pharmacy), and JPY146,000 (CAM). Annual direct nonmedical costs were JPY105,000 (caregiving), JPY22,000 (transportation), JPY30,000 (self-help devices), and JPY188,000 (house modifications). Based on the utilization rate for each cost component, the annual medical and nonmedical costs for each RA patient were JPY262,136 and JPY61,441, respectively. Costs increased with increasing RA disease activity and disability level or worsening quality of life (QOL).

CONCLUSIONS

Based on the IORRA database, patients with RA bear heavy economic burdens that increase as the disease is exacerbated. The results also suggest that the increase in medical and nonmedical costs may be ameliorated by the proactive control of disease activity.

Catastrophic health expenses and impoverishment of households of patients with rheumatoid arthritis

BACKGROUND

The cost of certain diseases may lead to catastrophic expenses and impoverishment of households without full financial support by the state and other organizations.

OBJECTIVE

To determine the socioeconomic impact of the rheumatoid arthritis (RA) cost in the context of catastrophic expenses and impoverishment.

PATIENTS AND METHODS

This is a cohort-nested cross-sectional multicenter study on the cost of RA in Mexican households with partial, full, or private health care coverage. Catastrophic expenses referred to health expenses totaling >30% of the total household income. Impoverishment defined those households that could not afford the Mexican basic food basket (BFB).

RESULTS

We included 262 patients with a mean monthly household income (US dollars) of $376 (0–18,890.63). In all, 50.8%, 35.5%, and 13.7% of the patients had partial, full, or private health care coverage, respectively. RA annual cost was $ 5534.8 per patient (65% direct cost, 35% indirect). RA cost caused catastrophic expenses in 46.9% of households, which in the logistic regression analysis were significantly associated with the type of health care coverage (OR 2.7, 95%CI 1.6–4.7) and disease duration (OR 1.024, 95%CI 1.002–1.046). Impoverishment occurred in 66.8% of households and was associated with catastrophic expenses (OR 3.6, 95%CI 1.04–14.1), high health assessment questionnaire scores (OR 4.84 95%CI 1.01–23.3), and low socioeconomic level (OR 4.66, 95%CI 1.37–15.87).

CONCLUSION

The cost of RA in Mexican households, particularly those lacking full health coverage leads to catastrophic expenses and impoverishment. These findings could be the same in countries with fragmented health care systems.

A case study for calculating employer costs for lost productive time in episodic migraine and chronic migraine: results of the American Migraine Prevalence and Prevention Study

OBJECTIVE

To model workplace lost productive time (LPT) from episodic migraine (EM) and chronic migraine (CM).

METHODS

We used published estimates of migraine epidemiology and related LPT to model the impact of migraine on two typical US workforce scenarios that differ by gender and age.

RESULTS

In a simulated service sector workforce of 10,000 individuals, the migraine-related LPT was $2.9 million annually compared with $2.1 million for a manufacturing workforce. Individuals with moderate frequency EM accounted for 42% of the cost. Individuals with high frequency EM and CM comprised 10% of all migraine sufferers and accounted for 22% of the LPT.

CONCLUSIONS

Lost productive time impact of migraine and other health problems depends on workforce demographics and the cost of labor. Employers can often estimate LPT costs to reveal priorities for optimizing use of health care.

Prognostic factors for long-term work disability due to musculoskeletal disorders

The objective of this study is to identify risk factors for permanent work disability (PWD) related to musculoskeletal disorders (MSDs). This is a secondary data analysis of a randomized controlled intervention study in Temporary Work Disability (TWD) due to MSDs. The association of PWD (claim submission and status recognition) with baseline clinical, sociodemographic, work-related administrative and occupational factors was analyzed by Cox proportional hazards models. Of 3,311 patients with TWD, 47 submitted a PWD claim, of whom 32 achieved PWD status. The main alleged causes of the PWD were back pain, sciatica, and inflammatory diseases. The following factors were independently associated with an increased probability of PWD claim submission: age (odds ratio (OR) 5.1), being woman (OR 2.1), self-employment (OR 3.4), unemployment (OR 13.8), previous musculoskeletal surgery (OR 16), repeated TWD (OR 3.4), sitting (OR 2.8), and raising arms frequently (OR 3.1). Patients with inflammatory disease were more likely to file PWD claims (OR 10.4) while tendonitis was associated with lower probability (OR 0.3). The sociodemographic factors that better predicted PWD status recognition were age (OR 5.7), low educational level (OR 4.2), previous musculoskeletal surgery (OR 14.9), unemployment (OR 17.6), sitting (OR 2.6), and raising arms frequently (OR 2.7). Inflammatory diseases were the diagnoses associated with a higher rate of PWD status recognition (OR 6.1). Inflammatory diseases have a high chronic disability potential in active workers. Sociodemographic, work-related, occupational factors, and other clinical factors, some of which are modifiable, may explain the development of long-term work disability related to MSDs.

Cost of illness for patients with arthritis receiving multidisciplinary rehabilitation care

Purpose. To describe healthcare consumption and costs prior to, during, and after multidisciplinary rehabilitation due to arthritis. Methods. 306 patients (age 18-75 years) with arthritis scheduled for multidisciplinary rehabilitation care in 9 rehabilitation centres and 4 rheumatology hospital departments were included and followed for 6 months. Costs were estimated in Euros (€) for the total sample and five clinical subgroups. Results. Healthcare costs ranged from €3,033 to €91,336 and were significantly higher at hospital departments compared to rehabilitation centres: €9,722 (SD 5,406) and €4,250 (SD 1,040). While total costs prior to and after rehabilitation were stable for those receiving rehabilitation at a hospital, there was a significant increase in costs for those being at a rehabilitation centre. Total mean costs were more than doubled when including social costs: from €32,410 (95% CI 20,074-37,017) to €51,491 (95% CI 49,055-61,657). Conclusions. Healthcare and social costs for arthritis rehabilitation were substantial both before and after a rehabilitation stay. It is important to explore methods to reduce the length of rehabilitation stay and production loss connected to rehabilitation of patients with rheumatic disease.

Cost-of-illness studies in systemic lupus erythematosus: A systematic review

OBJECTIVE

To summarize the state of knowledge regarding the economic burden of systemic lupus erythematosus (SLE) and to evaluate the quality of cost-of-illness (COI) studies conducted to date.

METHODS

Relevant literature was retrieved from the PubMed database in April 2010. The evaluation of identified articles was based on 7 key elements of COI studies derived from previous literature on health economics. Costs derived from each study were converted into 2008 US dollars using the Consumer Price Index and the purchasing power parity conversion rate.

RESULTS

A total of 11 articles were included in the evaluation. The average direct costs per patient-year ranged from $3,735-$14,410. Costs of inpatient care were found to be the largest component of direct costs in most of the studies. The employment rate varied from 35.8-55%. The average duration of annual short-term sick leave ranged from 7.0-64.8 days. The mean annual indirect costs per patient ranged from $1,093-$14,614, depending on the valuation method.

CONCLUSION

There is a substantial economic burden, in terms of health care resource utilization, associated with SLE, as well as losses of productivity due to work capacity impairment. The cost estimates in this review should be used with caution due to significant discrepancies in methodologies across studies. Future studies should address several methodologic considerations in order to measure the true costs related to SLE. Incidence-based COI studies are needed to evaluate the lifetime costs of SLE.

Osteoarthritis and absenteeism costs: evidence from US National Survey Data

OBJECTIVE

This study seeks to quantify the effects of osteoarthritis on the cost of absenteeism from work.

METHODS

This study performs multivariable analyses to examine the relationships between osteoarthritis and annual cost to employers that is associated with absenteeism. The cost is measured as the probability of absenteeism, days missed from work, and their dollar values, all indirect costs.

RESULTS

Osteoarthritis leads to a significantly higher probability of absenteeism and more days missed from work. Osteoarthritis increases annual per capita absenteeism costs by $469 for female workers and by $520 for male workers. This is equivalent to approximately 3 lost workdays. Aggregate annual absenteeism costs are $10.3 billion (women = $5.5 billion; men = $4.8 billion).

CONCLUSIONS

Aggregate annual absenteeism costs of osteoarthritis are quite substantial as measured by the probability of absenteeism, days missed from work, and their dollar values, compared with other major chronic diseases.

Sensory and vascular changes in a rat monoarthritis model: prophylactic and therapeutic effects of meloxicam

OBJECTIVE AND DESIGN

The objective of this study was to determine the ability of meloxicam prophylaxis and therapy to blunt the effect of complete Freund's adjuvant (CFA) induced monoarthritis.

MATERIALS AND METHODS

First the validity of this animal model was established by examining joint changes at multiple levels after injecting CFA into the tibio-tarsal joint. Next, meloxicam (5 mg/kg) or vehicle was administered on days 0-7 (prophylactic) and on days 7-16 (therapeutic) in separate groups of animals.

RESULTS

The CFA-injected joint demonstrated hallmark histological and structural changes such as pannus formation, bone remodeling, cartilage erosion and immune cell infiltration. Both prophylactic and therapeutic treatment with meloxicam effectively reduced swelling (ankle circumference), oedema and extravasation of Evans blue dye in the affected joint. Moreover, meloxicam reduced loss in range of motion and also reduced mechanical stimulus evoked pain scores. Notably, these effects persisted after discontinuing drug treatment.

CONCLUSION

The present study provides a unique comparison of prophylactic versus therapeutic effects of meloxicam in the CFA-induced model of monoarthritis.

Annual costs of rheumatoid arthritis in Turkey

Objective of the present study is aimed to determine costs of rheumatoid arthritis (RA) based on reimbursement agencies perspective [Social Security Institution (SSI)] in Turkey. The international clinical guidelines for RA are followed for analysing the direct costs. Data were collected from hospital bills, social security institution price lists, and Ministry of Health drug price list. Direct costs of RA patients were estimated as euro 2,669.14 patient/year. Outpatient costs were found to be euro 240.40. Routine tests during the year were calculated as euro 98.85. Ten percent of patients are hospitalized per year, and 0.62% of these patients received arthroplasty and/or other interventions. The cost during hospital stay was euro 87.76. euro 2,238 was determined as being paid per year for medication alone (including anti-TNF) and euro 4 is spent on auxiliary materials annually. Our data show a remarkable economic impact of RA over society. We hope that the cost of RA studies will help package price practices for reimbursement agencies.

Is it possible to identify early predictors of the future cost of chronic arthritis? The VErA project

This study was conducted to identify early predictors of the total cost of inflammatory arthritis (IA). One hundred and eighty patients affected by undifferentiated arthritis (UA) or rheumatoid arthritis (RA) were included in the French Very Early rheumatoid Arthritis (VErA) cohort between 1998 and 2001. Health economic data for 2003 were collected using a patient self-questionnaire. Results were analysed in terms of direct, indirect and total costs in 2003 euros (2003euro) for the population as a whole and in diagnostic subgroups. A payor perspective (the French National Health Insurance, in this case) was adopted. Multiple linear regression models were used to identify predictors of total cost from among the criteria assessed on recruitment. Results of the study showed that for the study population as a whole, the mean total cost was euro4700 per patient. The costs attributable to the RA and UA sub-groups were euro5928 and euro2424 per patient, respectively. In a univariate analysis, certain parameters were significantly correlated with a higher cost of illness. In the multivariate analysis, some of these parameters were further identified as being predictive of higher cost. Two strong significant, early predictors of total cost were identified: higher pain (P = 0.002) and the presence of rheumatoid factor (P = 0.004). In the RA sub-group, lower grip strength of the dominant hand (P = 0.039) was another predictor of the illness's subsequent economic impact. In conclusion, our data show that simple clinical and laboratory parameters can be used early in the course of IA to predict the condition's impact on healthcare budgets.

The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States

BACKGROUND

Low back pain (LBP) is a common symptom.

METHODS

Patient visits attributed to LBP in the National Ambulatory Medical Care Survey (NAMCS) during 2003-2004 served as the basis for epidemiological analyses (n = 1539). The subset of patient visits in which LBP was the primary reason for seeking care (primary LBP patient visits) served as the basis for medical management analyses (n = 1042). National population estimates were derived using statistical weighting techniques.

RESULTS

There were 61.7 million (SE, 4.0 million) LBP patient visits and 42.4 million (SE, 3.1 million) primary LBP patient visits. Only 55% of LBP patient visits were provided by primary care physicians. Age, geographic region, chronicity of symptoms, injury, type of physician provider, and physician specialty were associated with LBP patient visits. Age, injury, primary care physician status, type of physician provider, and shared physician care were associated with chronicity of LBP care. Osteopathic physicians were more likely than allopathic physicians to provide medical care during LBP patient visits (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.75-3.92) and chronic LBP patient visits (OR, 4.39; 95% CI, 2.47-7.80). Nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotic analgesics were ordered during 14.2 million (SE, 1.2 million) and 10.5 million (SE, 1.1 million) primary LBP patient visits, respectively. Drugs (OR, 0.29; 95% CI, 0.13-0.62) and, specifically, NSAIDs (OR, 0.40; 95% CI, 0.25-0.64) were ordered less often during chronic LBP patient visits compared with acute LBP patient visits. Overall, osteopathic physicians were less likely than allopathic physicians to order NSAIDs for LBP (OR, 0.43; 95% CI, 0.24-0.76). Almost two million surgical procedures were ordered, scheduled, or performed during primary LBP patient visits.

CONCLUSION

The percentage of LBP visits provided by primary care physicians in the United States remains suboptimal. Medical management of LBP, particularly chronic LBP, appears to over-utilize surgery relative to more conservative measures such as patient counseling, non-narcotic analgesics, and other drug therapies. Osteopathic physicians are more likely to provide LBP care, and less likely to use NSAIDs during such visits, than their allopathic counterparts. In general, LBP medical management does not appear to be in accord with evidence-based guidelines.

Prognostic factors in short-term disability due to musculoskeletal disorders

OBJECTIVE

To identify factors associated with poor outcome in temporary work disability (TWD) due to musculoskeletal disorders (MSDs).

METHODS

We conducted a secondary data analysis of a 2-year randomized controlled trial in which all patients with TWD due to MSDs in 3 health districts of Madrid (Spain) were included. Analyses refer to the patients in the intervention group. Primary outcome variables were duration of TWD and recurrence. Diagnoses, sociodemographic, work-related administrative, and occupational factors were analyzed by Cox proportional hazards models.

RESULTS

We studied 3,311 patients with 4,424 TWD episodes. The following were independently associated with slower return to work: age (hazard ratio [HR] 0.99, 95% confidence interval [95% CI] 0.98-0.99), female sex (HR 0.84, 95% CI 0.78-0.90), married (HR 0.90, 95% CI 0.83-0.97), peripheral osteoarthritis (HR 0.77, 95% CI 0.6-0.9), sciatica (HR 0.59, 95% CI 0.54-0.65), self-employment (HR 0.56, 95% CI 0.48-0.65), unemployment (HR 0.41, 95% CI 0.28-0.58), manual worker (HR 0.86, 95% CI 0.79-0.94), and work position covered during sick leave (HR 0.84, 95% CI 0.77-0.92). The factors that better predicted recurrence were peripheral osteoarthritis (HR 1.75, 95% CI 1.14-2.6), inflammatory diseases (HR 1.66, 95% CI 1.009-2.72), sciatica (HR 1.30, 95% CI 1.08-1.56), indefinite work contract (HR 1.43, 95% CI 1.14-1.75), frequent kneeling (HR 1.39, 95% CI 1.15-1.69), manual worker (HR 1.19, 95% CI 1.003-1.42), and duration of previous episodes (HR 1.003, 95% CI 1.001-1.005).

CONCLUSION

Sociodemographic, work-related administrative factors, diagnosis, and, to a lesser extent, occupational factors may explain the duration and recurrence of TWD related to MSD.

Gene therapy for arthritis

Arthritis is among the leading causes of disability in the developed world. There remains no cure for this disease and the current treatments are only modestly effective at slowing the disease's progression and providing symptomatic relief. The clinical effectiveness of current treatment regimens has been limited by short half-lives of the drugs and the requirement for repeated systemic administration. Utilizing gene transfer approaches for the treatment of arthritis may overcome some of the obstacles associated with current treatment strategies. The present review examines recent developments in gene therapy for arthritis. Delivery strategies, gene transfer vectors, candidate genes, and safety are also discussed.

Medical care expenditures and earnings losses among persons with arthritis and other rheumatic conditions in 2003, and comparisons with 1997

OBJECTIVE

To obtain estimates of medical care expenditures and earnings losses associated with arthritis and other rheumatic conditions and the increment in such costs attributable to arthritis and other rheumatic conditions in the US in 2003, and to compare these estimates with those from 1997.

METHODS

Estimates for 2003 were derived from the Medical Expenditures Panel Survey (MEPS), a national probability sample of households. We tabulated medical care expenditures of adult MEPS respondents, stratified by arthritis and comorbidity status, and used regression techniques to estimate the increment of medical care expenditures attributable to arthritis and other rheumatic conditions. We also estimated the earnings losses sustained by working-age adults with arthritis and other rheumatic conditions. Estimates for 2003 were compared with those from 1997, inflated to 2003 terms.

RESULTS

In 2003, there were 46.1 million adults with arthritis and other rheumatic conditions (versus 36.8 million in 1997). Adults with arthritis and other rheumatic conditions incurred mean medical care expenditures of $6,978 in 2003 (versus $6,346 in 1997), of which $1,635 was for prescriptions ($899 in 1997). Expenditures for adults with arthritis and other rheumatic conditions totaled $321.8 billion in 2003 ($233.5 billion in 1997). In 2003, the mean increment in medical care expenditures attributable to arthritis and other rheumatic conditions was $1,752 ($1,762 in 1997), for a total of $80.8 billion ($64.8 billion in 1997). Persons with arthritis and other rheumatic conditions ages 18-64 years earned $3,613 less than other persons (versus $4,551 in 1997), for a total of $108.0 billion (versus $99.0 billion). Of this amount, $1,590 was attributable to arthritis and other rheumatic conditions (versus $1,946 in 1997), for a total of $47.0 billion ($43.3 billion in 1997).

CONCLUSION

Our findings indicate that the increase in medical care expenditures and earnings losses between 1997 and 2003 is due more to an increase in the number of persons with arthritis and other rheumatic conditions than to costs per case.

True difference or something else? Problems in cost of osteoarthritis studies

OBJECTIVES

To identify the commonalities and discrepancies among the published cost of osteoarthritis (OA) studies and to further propose some potential improvements for this type of research.

METHODS

A systematic literature review was performed on MEDLINE (1966 to April 2006) by using 2 overlapping search strategies to identify cost of illness studies in OA based on the predefined eligible criteria. Direct and indirect costs per patient per annum were separately summarized across studies and countries. The sample size-weighted mean was calculated when there were 2 or more studies from the same country. Discount rates of 3% and appropriate exchange rates were used in conversion of the costs reported in different years and different currencies to 2005 US dollars.

RESULTS

Ten articles fulfilling the eligible criteria were included in the literature synthesis. Of these, 4 were from the USA, 2 each from Canada and France, and 1 each from Italy and Hong Kong. After adjusted to 2005 US dollars, annual direct costs per patient (in descending order) were $9147 in Hong Kong, $4792 in USA, $2878 in Canada, $1271 in Italy, and $345 in France. In contrast, indirect costs were only reported by 5 studies in 4 countries. The highest indirect costs were $9847 per patient per annum in Canada and the lowest were $864 in Hong Kong.

CONCLUSIONS

The observed substantial variations in costs of OA across studies and countries may not reflect the true differences among them. The comparability across these identified studies is quite limited, which highlights the importance of standardization in cost of OA studies.

The Indirect Costs of Arthritis Resulting From Unemployment, Reduced Performance, and Occupational Changes While at Work

OBJECTIVE

The objective of this study was to assess the cost attributable to lost productivity from arthritis and the association between the degree of loss and demographic, disease-related, occupational, and psychosocial variables for people.

METHODS

In a prospective study, 383 employed individuals with arthritis were recruited from southwestern Ontario, Canada. Respondents completed structured questionnaires assessing demographic, disease-related, workplace, and psychosocial variables as well as employment-related transitions at 2 time points 18 months apart. Indirect costs resulting from arthritis-related absences, reduced performance, decreased work hours, job change, and work disability were estimated. A proportional odds model was used to assess the impact of the various variables on lost productivity.

RESULTS

The average cost attributable to arthritis was CAN Dollars 11,553(Dollars CAN = 0.75 Dollars US) per person per year. The largest component of the loss was the result of reduced performance at work, which accounted for 41% (Dollars 4724) of the total loss. This was followed by wage loss resulting from stopping working or changing jobs, which comprised 37% (Dollars 4309) of the total. Another 12% (Dollars 1398) and 10% (Dollars 1121) of the loss were the result of the decrease in hours of work and absenteeism, respectively. Four variables were associated with the productivity loss: greater symptom severity (odds ratio [OR] = 1.11), low or medium control over the work schedule (OR = 0.55 and 0.60, respectively), greater workspace limitation (OR = 1.10), and higher depression (OR = 1.04).

CONCLUSIONS

Indirect arthritis-related costs are substantial. Our results show that not only the disease itself, but also psychosocial and work-related factors affect the magnitude of the costs.

Work disability in rheumatoid arthritis is predicted by physical and psychological health status: a 7-year study from the Oslo RA register

OBJECTIVE

To explore the prevalence of work disability (WD) and to identify bio-psychological factors that predicts future WD in rheumatoid arthritis (RA) over a 7-year period.

METHODS

Patients were selected from the Oslo RA register. The prevalence of WD was studied cross-sectionally among respondents <67 years (n = 526) in a postal survey. Mean age (SD) was 51.1 (11.9) years, mean disease duration 11.3 (9.4) years, and 49% of patients were RF-positive. The patients studied for predictive factors for WD were respondents in postal surveys both at baseline and at the 7-year follow-up, in work at baseline and still in working age (<67 years) at follow-up (n = 159). Mean age at baseline (SD) was 44.5 (9.7) years, mean disease duration 8.4 (6.6) years, mean years of formal education 12.7 (3.1) years, 48% were RF-positive. Assessments included socio-demographic variables and health status measures (MHAQ, AIMS2, SF-36, fatigue and pain on VAS 0-100 mm, self efficacy, and RAI as a measure for helplessness).

RESULTS

Among the 526 respondents at baseline <67 years, the prevalence of WD was 40%. A high level of education was a predictor of reduced risk of work disability [odds ratio (OR) = 0.4, 95% confidence interval (CI) 0.1; 0.9], while female gender (OR 3.0, 95% CI 1.1; 8.0), physical disability (MHAQ-score) (OR = 3.9, 95% CI 1.2; 12.5) and helplessness over median RAI-score (OR = 3.0, 95% CI 1.4; 6.7) were independent predictors of increased risk for new work disability over 7 years.

CONCLUSION

Physical disability, increased helplessness, low formal education, and female gender were found to be independent risk factors for new work disability over the 7-year study period.

Cost of illness in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and systemic lupus erythematosus in Germany

OBJECTIVE

To estimate and compare the direct and indirect costs of illness in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE), and to evaluate the effect of sex, disease duration and functional status on the various cost domains.

METHODS

Data of outpatients, aged 18-65, with rheumatoid arthritis (n = 4351), ankylosing spondylitis (n = 827), PsA (n = 908) or SLE (n = 844), who were enrolled in the national database of the German collaborative arthritis centres in 2002, were analysed. Data on healthcare consumption, out-of-pocket expenses and productivity losses were derived from doctors and patients. For the calculation of indirect costs, the human capital approach (HCA) and the friction cost approach (FCA) were applied.

RESULTS

Mean direct costs amounted to 4737 euros a year in rheumatoid arthritis, 3676 euros in ankylosing spondylitis, 3156 euros in PsA and 3191 euros in SLE. By using the HCA, total costs were calculated at 15,637 euros in rheumatoid arthritis, 13,513 euros in ankylosing spondylitis, 11,075 euros in PsA and 14,411 euros in SLE, whereas with the FCA the numbers were 7899 euros, 7204 euros, 5570 euros and 6518 euros, respectively. Costs increased with disease duration and were strongly dependent on functional status. In patients with the highest disability (<50% of full function), the total costs on applying the HCA were 34,915 euros in rheumatoid arthritis, 29,647 euros in alkylosing spondylitis, 37,440 euros in PsA and 32,296 euros in SLE.

CONCLUSION

The costs of illness are high in all four diseases, with a strong effect of functional status on total costs. Indirect costs differ by the factor 3, based on whether the HCA or the FCA is used.

Direct costs related to rheumatoid arthritis: the patient perspective

OBJECTIVE

To determine rheumatoid arthritis related out of pocket expenditure (OOPE) in Germany and to disaggregate the total OOPE into contributing cost domains.

METHODS

Data for the cost analysis were drawn from a multicentre randomised controlled prospective trial to assess the effectiveness of clinical quality management in patients with rheumatoid arthritis. Both payer sources and patient cost questionnaires were used to generate health care utilisation data. All cost domains of a recently published matrix were reviewed and potential sources of OOPE were determined. Health care utilisation data were developed throughout 2001. Co-payment regulations as per January 2004 were applied in order to indicate the most recent level of OOPE in Germany. Data were analysed in both physical and monetary units using descriptive statistics.

RESULTS

In all, 136 patients with rheumatoid arthritis were included. Mean total OOPE per patient and year was 417.20 Euro (SEM 38.8, median 271.2). OOPE accounted for 15.3% of the total direct costs of rheumatoid arthritis. Total OOPE were further subdivided into cost domains: "non-physician service utilisation"' (194.40 Euro per patient and year; SEM 24.2), "medication" (99.00 Euro; 6.1), "transportation" (56.20 Euro; 17.4), "visits to physicians" (38.40 Euro; 0.6), "hospital facilities" (24.00 Euro; 5.6), and "devices and aids" (5.10 Euro; 0.8).

CONCLUSIONS

Rheumatoid arthritis is associated with substantial OOPE, imposing a considerable economic burden for patients. OOPE contribute significantly to the total health care expenditure in rheumatoid arthritis. The patient perspective has to be taken into account when calculating the overall direct costs of rheumatoid arthritis from a societal point of view.

[Out-of-pocket medical spending for care in patients with recent onset rheumatoid arthritis]

We examined out-of-pocket medical expenditures (OoP) of 869 patients with recent onset rheumatoid arthritis (ACR criteria, disease duration <2 years) using data from a prospective observational cohort. Out-of-pocket costs were retrospectively assessed for a period of 6 months by a list of 14 cost domains. Of the patients, 82% had costs due to copayments for prescribed drugs and 56% for over-the-counter drugs. Within six months each patient spent an average of 47 (+/- 67) Euro as co-payment and 45 (+/- 96) Euro for over-the-counter drugs. A comparable sum was spent for complementary and alternative medicine (47+/-250 Euro), which was used by 14% of the patients. The mean total OoP expenditure caused by RA was 628 Euro p.a. (median 306, IQ 66-334 Euro). The median costs accounted for approximately 2% of the average disposable yearly income in Germany. Out-of-pocket spending increased with functional limitations, poor health condition and pain as well as with level of education. A multivariate logistical regression analysis showed that patients with these characteristics spent about twice as much as patients with mild disease or low educational level. The odds ratios for having more than 306 Euro OoP-costs p.a. were OR=2.6 (CI 1.7-4) for patients with severe vs. moderate functional disability (HAQ> or =1.5 vs <1.5), OR=2.4 (CI 1.4-4.4) for patients in poor vs. good health condition (NRS 7-10 vs 0-3), and OR=2.1 for patients with severe vs. mild pain (CI 1.4-3.3). The level of OoP spending also varied by employment status (OR=0.28; CI 0.1-0.6 for jobless vs employed patients). Despite almost universal insurance coverage in Germany, patients with rheumatoid arthritis were exposed to substantial OoP expenditures. As policymakers discuss cost sharing and design of benefit packages to contain health spending, it is important to consider the expenditures that persons with chronic conditions like rheumatoid arthritis already have.

Burden and cost of illness in patients with juvenile idiopathic arthritis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health-Related Lost Productive Time (LPT): Recall Interval and Bias in LPT Estimates

We examined the effect of interview characteristics (ie, recall interval, interview version) on estimates of health-related lost productive work time (LPT). Three versions of a telephone interview were administered using 7-day and 4-week recall periods. In a population-based survey, 7674 workers randomly were assigned to one of six interviews at contact; 615 participants received a follow-up interview. We found strong evidence of under-reporting using a 4-week recall period and a not significant trend in over-reporting LPT using a 7-day recall period. Of the three interviews, version 3 could be administered most quickly, on average, and yielded the most discriminating estimates of LPT by health condition (ie, headache, allergic rhinitis, and cold/flu). Our data suggest that variation in relatively short recall periods influences estimates of health-related LPT. A 2-week recall period may be optimal for minimizing overall reporting error but requires additional research to verify.