Monetary value of lost productivity over a five year follow up in early rheumatoid arthritis estimated on the basis of official register data on patients' sickness absence and gross income: experience from the FIN-RACo trial

Physical Exercise and Occupational Therapy at Home to Improve the Quality of Life in Subjects Affected by Rheumatoid Arthritis: A Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that affects synovial membranes and typically causes joint pain and swelling. The resulting disability of RA is due to the erosion of cartilage and bone from the inflamed synovial tissue. Occupational therapy is a strategy and technique to minimize the joints' fatigue and effort. At the same time, physical exercise reduces the impact of systemic manifestations and improves symptoms in RA. This study investigates the role of a 30-day joint economy intervention (integration of physical exercise and occupational therapy) at home on the quality of life of subjects with RA.

METHODS

One hundred and sixty outpatients with RA were enrolled in a single-center trial with PROBE design and were divided into the intervention group (IG), which combined joint protection movements and physical exercise to maintain muscle tone at home, and the control group (CG). Both groups included 80 patients. In all patients, data from the disease activity score (DAS 28), health assessment questionnaire (HAQ), and short-form health survey (SF-12) "Italian version" were collected. In addition, to IG, a brochure was distributed, and the joint economy was explained, while to CG, the brochure only was distributed. The comparison between groups was made using Fisher's exact test for contingency tables and the z-test for the comparison of proportions. The non-parametric Mann-Whitney U test was used to compare quantitative variables between groups. The Wilcoxon signed-ranked test was used for post-intervention versus baseline comparisons.

RESULTS

Among the recruited patients, 54% were female. The mean age was 58.0 (42.4-74.7) for the CG and 54.0 (39.7-68.3) for the IG. Patients included in the IG had a higher cumulative illness rating scale for the evaluation of severity and comorbidity index (2.81 vs. 2.58; 2.91 vs. 2.59, respectively), as well as morning stiffness (33.8 vs. 25.0), even if not significant compared with CG patients. Our results indicate that, after 30 days of joint economy intervention at home, the DAS28 erythrocyte sedimentation rate (esr) and DAS28 C-reactive protein (crp), HAQ, and SF-12 mental component score were significantly improved (p = 0.005, p = 0.004, p = 0.009, and p = 0.010, respectively).

CONCLUSIONS

Our findings show that the combination of physical exercise and occupational therapy positively affects patients' quality of life with RA considering disease activity, global health status, and mental health.

Health-Care and Societal Costs Associated with Non-Persistence with Subcutaneous TNF-α Inhibitors in the Treatment of Inflammatory Arthritis (IA): A Retrospective Observational Study

Objective

A few studies have suggested that patients with inflammatory arthritis (IA) who remain persistent with subcutaneous TNF-α inhibitors (SC-TNFi) incur lower health care costs than patients who discontinue treatment, whereas data on the impact of non-persistence on indirect costs are largely lacking. Furthermore, existing estimates are based on fixed follow-ups, in relation to treatment initiation, and therefore do not measure costs in direct relation to treatment discontinuation. Therefore, by capturing costs in direct relation to treatment discontinuation, this study aimed to estimate direct and indirect costs associated with non-persistence with SC-TNFis in IA.

Methods

Adult Swedish biologic-naïve IA patients initiating biologic treatment with a SC-TNFi (adalimumab, etanercept, certolizumab or golimumab) between May 6, 2010, and December 31, 2017, were identified in population-based registers with almost complete coverage. IA was defined as a diagnosis of rheumatic arthritis, ankylosing spondylitis/unspecified spondyloarthritis or psoriatic arthritis. Non-persistent patients were matched on propensity score to patients persistent with treatment by at least an additional 12 months. This enabled comparisons of direct healthcare costs and indirect costs for sick leave and disability pension, respectively, 12 months before and 12 months after treatment discontinuation.

Results

A balanced cohort of 486 matched pairs was generated. The total direct and indirect costs were significantly higher among non-persistent patients already during the 12 months before index ($20,802 [18,335–23,429] vs. $16,600 [14,331–18,696]). However, while non-persistent patients increased their total direct and indirect costs, persistent patients significantly decreased the same, further widening the difference in costs during the 12-month period after index date ($22,161 [19,754–24,556] vs. $13,465 [11,415–15,729]).

Conclusions

Among biologic-naïve Swedish IA patients treated with SC-TNFis, persistent patients incurred about 40% lower aggregated direct and indirect costs compared to non-persistent patients the year following SC-TNFi discontinuation. This highlights the impact of treatment persistence from an economic viewpoint, adding further aspects to the clinical perspective.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01970-w.

Patient-Reported Outcomes Are More Important Than Objective Inflammatory Markers for Sick Leave in Biologics-Treated Patients With Rheumatoid Arthritis

OBJECTIVE

To study the impact of common noncomposite disease activity measures on sick leave in biologics-treated patients with rheumatoid arthritis (RA).

METHODS

Data from study visits by biologics-treated RA patients of working age (<65 years) in the observational South Swedish Arthritis Treatment Group Register between 2005 and 2011, were included (5,118 visits by 941 patients). We performed association analyses between various noncomposite disease activity measures at each visit and the number of days of sick leave during the subsequent month; this information was retrieved from the Social Insurance Agency. Adjusted separate generalized estimating equation regression models were used, and analyses were stratified according to sick leave status for the month preceding each visit (no, partial, or full sick leave). Results are presented as standardized beta coefficients for comparability.

RESULTS

Among modifiable noncomposite disease activity measures, patient's assessment of pain and disease activity scored on a visual analog scale (VAS) were most strongly associated with subsequent sick leave, irrespective of baseline sick leave status. Generally, measures that were more objective (swollen joint count, erythrocyte sedimentation rate, and C-reactive protein) had less impact on sick leave compared with variables that were more subjective (patient's pain and global scores on a VAS, evaluator's global assessment of disease activity on a 5-grade Likert scale, and tender joint count).

CONCLUSION

Measures of disease activity that are more subjective have a greater impact on sick leave in biologics-treated patients with RA compared with variables that are more objective, suggesting a stronger focus on subjective measures when targeting work loss or intervening to reduce it.

Clinical Characteristics in Patients with Rheumatoid Arthritis: Differences between Genders

Objective

To compare the clinical characteristics of a group of men and women with rheumatoid arthritis (RA) and determine the differences between genders.

Materials and Methods

A descriptive and comparative cross-sectional study was developed with a group of 50 men and a control group of 50 women with RA, from a rheumatology center in the city of Guayaquil, Ecuador. Data collected included clinical manifestations, comorbidities, treatment, and disease activity. Clinical and activity differences between sexes were analyzed.

Results

Women were more devoted to housework (66%), while men consumed more tobacco (34%) and alcohol (38%). Fatigue (60%), loss of appetite (54%), and weight loss (44%) were more common in women. No differences were found in comorbidities or treatment. Women had higher values of DAS-28 (3.4 vs 2.5), HAQ-DI (1.1 vs 0.4), ESR (33.0 vs 23.2), painful joints (8 vs 3), swollen joints (6 vs 2), and overall physician assessment (3 vs 2).

Conclusion

The results are similar to other publications that establish that women have a more aggressive disease with greater activity of the disease and disability.

Similar Improvements in Patient-Reported Outcomes Among Rheumatoid Arthritis Patients Treated with Two Different Doses of Methotrexate in Combination with Adalimumab: Results From the MUSICA Trial

INTRODUCTION

In patients with rheumatoid arthritis (RA), combination treatment with methotrexate (MTX) and adalimumab is more effective than MTX monotherapy. From the patients' perspective, the impact of reduced MTX doses upon initiating adalimumab is not known. The objective was to evaluate the effects of low and high MTX doses in combination with adalimumab initiation on patient-reported outcomes (PROs), in MTX-inadequate responders (MTX-IR) with moderate-to-severe RA.

METHODS

MUSICA was a randomized, double-blind, controlled trial evaluating the efficacy of 7.5 or 20 mg/week MTX, in combination with adalimumab for 24 weeks in MTX-IR RA patients receiving prior MTX ≥ 15 mg/week for ≥ 12 weeks. PROs were recorded at each visit, including physical function, health-related quality-of-life, work productivity, quality-of-sleep, satisfaction with treatment medication, sexual impairment due to RA, patient global assessment of disease activity (PGA), and patient pain. Last observation carried forward was used to account for missing values.

RESULTS

At baseline, patients in both MTX dosage groups had similar demographics, disease characteristics, and PRO scores. Overall, initiation of adalimumab led to significant improvements from baseline in the PROs assessed for both MTX dosage groups. Improvements in presenteeism from baseline were strongly correlated with corresponding improvements in SF-36 (vitality), pain, and physical function. Physical and mental well-being had a good correlation with improvement in sleep. Overall, improvements in disease activity from baseline were correlated with improvements in several PROs.

CONCLUSIONS

The addition of adalimumab to MTX in MTX-IR patients with moderate-to-severe RA led to improvements in physical function, quality-of-life, work productivity, quality of sleep, satisfaction with treatment medication, and sexual impairment due to RA, regardless of the concomitant MTX dosage.

FUNDING

AbbVie.

TRIAL REGISTRATION

Clinicaltrials.gov identifier, NCT01185288.

Modeled Health Economic Impact of a Hypothetical Certolizumab Pegol Risk-Sharing Scheme for Patients with Moderate-to-Severe Rheumatoid Arthritis in Finland

PURPOSE

To model the American College of Rheumatology (ACR) outcomes, cost-effectiveness, and budget impact of certolizumab pegol (CZP) (with and without a hypothetical risk-sharing scheme at treatment initiation for biologic-naïve patients) versus the current mix of reimbursed biologics for treatment of moderate-to-severe rheumatoid arthritis (RA) in Finland.

METHODS

A probabilistic model with 12-week cycles and a societal approach was developed for the years 2015-2019, accounting for differences in ACR responses (meta-analysis), mortality, and persistence. The risk-sharing scheme included a treatment switch and refund of the costs associated with CZP acquisition if patients failed to achieve ACR20 response at week 12. For the current treatment mix, ACR20 at week 24 determined treatment continuation. Quality-adjusted life years were derived on the basis of the Health Utilities Index.

RESULTS

In the Finnish target population, CZP treatment with a risk-sharing scheme led to a estimated annual net expenditure decrease ranging from 1.7% in 2015 to 5.6% in 2019 compared with the current treatment mix. Per patient over the 5 years, CZP risk sharing was estimated to decrease the time without ACR response by 5%-units, decrease work absenteeism by 24 days, and increase the time with ACR20, ACR50, and ACR70 responses by 5%-, 6%-, and 1%-units, respectively, with a gain of 0.03 quality-adjusted life years. The modeled risk-sharing scheme showed reduced costs of €7866 per patient, with a more than 95% probability of cost-effectiveness when compared with the current treatment mix.

CONCLUSION

The present analysis estimated that CZP, with or without the risk-sharing scheme, is a cost-effective alternative treatment for RA patients in Finland. The surplus provided by the CZP risk-sharing scheme could fund treatment for 6% more Finnish RA patients.

FUNDING

UCB Pharma.

Infliximab Versus Conventional Combination Treatment and Seven-Year Work Loss in Early Rheumatoid Arthritis: Results of a Randomized Swedish Trial

Objective

To compare long‐term work loss in methotrexate‐refractory early rheumatoid arthritis (RA) patients randomized to the addition of infliximab or conventional combination treatment.

Methods

This study was a multicenter, 2‐arm, parallel, randomized, active‐controlled, open‐label trial. RA patients with <1‐year symptom duration were recruited from 15 rheumatology clinics in Sweden between 2002–2005. Patients who did not achieve low disease activity after 3–4 months of methotrexate therapy were randomized to the addition of infliximab or conventional combination treatment with sulfasalazine plus hydroxychloroquine. Yearly sick leave and disability pension days >7 years after randomization were retrieved from nationwide registers kept by the Swedish Social Insurance Agency.

Results

Of 210 working‐age patients, 109 were randomized to infliximab (mean age 48.4 years, 73% women) and 101 to conventional treatment (mean age 48.7 years, 77% women). The year before randomization, the mean number of annual work days lost was 127 in the infliximab arm and 118 in the conventional treatment group (mean difference 9 [95% confidence interval (95% CI) −23, 39]). Compared to the year before randomization, the mean changes at 7 years were −25 days in the infliximab and −26 days in the conventional treatment group (adjusted mean difference 10 [95% CI −25, 46]). The cumulative mean for work‐loss days was 846 in the infliximab group and 701 in the conventional treatment group (adjusted mean difference 104 [95% CI −56, 284]).

Conclusion

Long‐term work loss improved significantly in early RA patients randomized to infliximab plus methotrexate or conventional combination therapy. No difference was detected between strategies, and the level of work‐loss days remained twice that observed in the general population.

Predictors of work disability after start of anti-TNF therapy in a national cohort of Swedish patients with rheumatoid arthritis: does early anti-TNF therapy bring patients back to work?

OBJECTIVES

To examine predictors of work ability gain and loss after anti-tumour necrosis factor (TNF) start, respectively, in working-age patients with rheumatoid arthritis (RA) with a special focus on disease duration.

METHODS

Patients with RA, aged 19-62 years, starting their first TNF inhibitor 2006-2009 with full work ability (0 sick leave/disability pension days during 3 months before bio-start; n=1048) or no work ability (90 days; n=753) were identified in the Swedish biologics register (Anti-Rheumatic Treatment In Sweden, ARTIS) and sick leave/disability pension days retrieved from the Social Insurance Agency. Outcome was defined as work ability gain ≥50% for patients without work ability at bio-start and work ability loss ≥50% for patients with full work ability, and survival analyses conducted. Baseline predictors including disease duration, age, sex, education level, employment, Health Assessment Questionnaire, Disease Activity Score 28 and relevant comorbidities were estimated using Cox regression.

RESULTS

During 3 years after anti-TNF start, the probability of regaining work ability for totally work-disabled patients was 35% for those with disease duration <5 years and 14% for disease duration ≥5 years (adjusted HR 2.1 (95% CI 1.4 to 3.2)). For patients with full work ability at bio-start, disease duration did not predict work ability loss. Baseline disability pension was also a strong predictor of work ability gain after treatment start.

CONCLUSIONS

A substantial proportion of work-disabled patients with RA who start anti-TNF therapy regain work ability. Those initiating treatment within 5 years of symptom onset have a more than doubled 3-year probability of regaining work ability compared with later treatment starts. This effect seems largely due to the impact of disease duration on disability pension status.

Longterm Work Productivity Costs Due to Absenteeism and Permanent Work Disability in Patients with Early Rheumatoid Arthritis: A Nationwide Register Study of 7831 Patients

Objective.

To estimate the development and potential disproportional distribution of longterm productivity costs (PC) and their determinants leading to work absenteeism and permanent work disability in working-aged patients with early rheumatoid arthritis (RA).

Methods.

A cohort of subjects with early RA was created by identifying the new cases of RA from the national drug reimbursement register that had been granted a special reimbursement for their antirheumatic medications for RA from 2000–2007. The dataset was enriched by cross-linking with other national registries detailing work absenteeism days and permanent disability pensions. In the base case, the human capital approach was applied to estimate PC based on subjects’ annual number of absenteeism days and incomes. Hurdle regression analysis was applied to study the determinants of PC.

Results.

Among the 7831 subjects with early RA, the mean (bootstrapped 95% CI) annual PC per person-observation year was €4800 (4547–5070). The annual PC declined after the first year of RA diagnosis, but increased significantly in subsequent years. In addition, the PC was heavily disproportionally concentrated in a small fraction of patients with RA, because only around 20% of patients accounted for the majority of total annual PC. The initiation of active drug treatment during the first 3 months after RA diagnosis significantly reduced the cumulative PC when compared with no drug treatment.

Conclusion.

The longterm PC increased significantly in parallel with years elapsing after RA diagnosis. Further, the majority of these PC are incurred by a small proportion of patients.

Variability in the frequency of rheumatology consultations in patients with rheumatoid arthritis in Spain

The aim of this work was to assess the variability in the use of health-care resources, based on the number of visits to rheumatology departments by rheumatoid arthritis patients, in Spain, and its association with patient, physician and center characteristics. The sample consisted of patient records of men and women (aged 16 or older), with a clinical diagnosis of RA, who met the American Rheumatism Association 1987 revised criteria and who had been treated in a rheumatology department at a Spanish hospital with at least one visit to a rheumatologist during the two years preceding the date of the study. To analyze which variables were independently associated with the number of consultations, those with a statistically significant result in the bivariate analysis, or which were clinically relevant or deemed confounders, were used in the construction of a linear regression model. The records of 1188 RA patients were studied. The linear regression model explained the 26.67 % of the variability in the number of visits. The number of csDMARDs prescribed, the administration of biological therapy, corticoid prescription, the presence of nursing consultation, mean time to first visit in the department and attended population showed a positive significant association, while the presence of telephone consultation, distance from the hospital to the patient´s residence (≥20 km) and drug monitoring by rheumatology department + primary care physician or by other specialists were negatively associated with the number of consultations. We observed a high variability in the number of visits, which remains partially unexplained even after taking into account individual, physician and center characteristics.

Effect of Rheumatoid Arthritis on Longterm Sickness Absence in 1994-2011: A Danish Cohort Study

OBJECTIVE

By linkage of national registries, we investigated the risk of longterm sickness absence (LTSA) ≥ 3 weeks in a large cohort of Danish patients with rheumatoid arthritis (RA) and non-patients. The study aimed to (1) estimate the risk of LTSA for patients with RA compared with the general population, (2) examine whether the risk of LTSA has changed in recent years, and (3) evaluate the effect of other risk factors for LTSA (e.g., physical work demands, age, sex, education, and psychiatric and somatic comorbidities).

METHODS

A total of 6677 patients with RA aged 18-59 years in the years 1994-2011 were identified in registries and compared with 56,955 controls from the general population matched by age, sex, and city size. The risk of LTSA was analyzed using Cox proportional hazards models with late entry, controlling for other risk factors and assuming separate risks in the first year after diagnosis and the following years.

RESULTS

Compared with the general population, patients with RA had increased risk of LTSA in the first year after diagnosis (HR 5.4 during 1994-1999, 95% CI 4.2-6.8) and in following years (HR 2.4, 95% CI 2.1-2.8). For established RA (> 1 yr after diagnosis), the excess was 20% lower in 2006-2011 (HR 1.9, 95% CI 1.7-2.2) compared with 1994-1999 (p < 0.001). For patients with RA and controls, older age, shorter education, a physically demanding job, and somatic and/or psychiatric comorbidities increased the risk of LTSA.

CONCLUSION

While improvements were observed from 1994-1999 to 2006-2011, patients with RA have significant increased risk of LTSA, in particular in the first year after diagnosis.

Systematic Literature Review on ICF From 2001 to 2013 in the Nordic Countries Focusing on Clinical and Rehabilitation Context

We present a systematic review on International Classification of Functioning, Disability and Health (ICF) used in the Nordic countries from 2001 through 2013, describing and quantifying the development in utilization of ICF, and describe the extent to which the different components of the ICF have been used. A search was conducted in EMBASE, MEDLINE and PsycInfo. Papers from Nordic countries were included if ICF was mentioned in title or abstract. Papers were assigned to one of eight categories covering the wide rehabilitation area; furthermore, area of focus was assigned. Use of ICF components and intervention were coded in papers categorized as "clinical and/or rehabilitation contexts" or "non-clinical contexts". One hundred seventy papers were included, of these 99 papers were from the categories "clinical and/or rehabilitation contexts" or "non-clinical contexts". Forty-two percent of the 170 included papers were published in the period 2011 - 2013. There was an increase in ICF-relevant papers from 2001 to 2013, especially in the categories "clinical and/or rehabilitation contexts" and "non-clinical contexts". The most represented focus areas were neurology, musculoskeletal, and work-related areas. All five or at least four ICF components were mentioned in the results or discussions in most papers, and activity was most frequently mentioned.

Estimating the monetary value of the annual productivity gained in patients with early rheumatoid arthritis receiving etanercept plus methotrexate: interim results from the PRIZE study

Objective

To measure and value the impact of combined etanercept (ETN) and methotrexate (MTX) therapy on work productivity in patients with early rheumatoid arthritis (RA) over 52 weeks.

Methods

MTX- and biological-naïve patients with RA (symptom onset ≤12 months; Disease Activity Score based on a 28-joint count (DAS28) >3.2) received open-label ETN50/MTX for 52 weeks. The Valuation of Lost Productivity (VOLP) questionnaire, measuring paid and unpaid work productivity impacts, was completed approximately every 13 weeks. Bootstrapping methods were used to test changes in VOLP outcomes over time. One-year productivity impacts were compared between responders (DAS28 ≤3.2) at week 13 and non-responders using zero-inflated models for time loss and two-part models for total costs of lost productivity.

Results

196 patients were employed at baseline and had ≥1 follow-up with VOLP. Compared with baseline, at week 52, patients gained 33.4 h per 3 months in paid work and 4.2 h per week in unpaid work. Total monetary productivity gains were €1322 per 3 months. Over the 1-year period, responders gained paid (231 h) and unpaid work loss (122 h) compared with non-responders, which amounted to a gain of €3670 for responders.

Conclusions

This is the first clinical trial to measure and value the impact of biological treatment on all the labour input components that affect overall productivity. Combination therapy with ETN50/MTX was associated with a significant productivity gain for patients with early RA who were still observed at week 52. Over the 1-year treatment period, responders at week 13 suffered significantly less productivity loss than non-responders suggesting this gain was related to treatment response.

Trial registration number

ClinicalTrials.gov number NCT00913458

[Occupational therapy in rheumatoid arthritis: what rheumatologists need to know?]

Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of intervention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient's functionality. Occupational therapy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupational therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and coping with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and independence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA.

Work productivity loss in early arthritis during the first 3 years of disease: a study from a French National Multicenter Cohort

OBJECTIVE

To assess work productivity (WP) loss during the first 3 years of disease in a cohort of patients with early arthritis (EA) diagnosed between 2002 and 2005.

METHODS

The ESPOIR (Etude et Suivi des Polyarthrites Indifférenciées Récentes) cohort included 813 EA patients; we included those of working age at baseline in the present study. WP loss was assessed by 3 components: sick leave, permanent disability, and early retirement. The proportion of affected patients and the mean number of days off work were assessed for each component. WP costs were estimated and determinants of positive and extreme costs were assessed by logistic regression models.

RESULTS

Among the 664 patients included, 81.6% were in the workforce at baseline. During the first 3 years of disease, 45% reported at least 1 sick leave day and 11% reported permanent disability. Only a few patients (1%) reported early retirement. The mean number of days on sick leave due to EA decreased regularly from 44 to 13, whereas the mean number of days on permanent disability tripled from 10 to 33. The mean annual cost was 1,333 (95% confidence interval 1,075-1,620). Sick leave longer than 30 days due to EA before inclusion and a decrease in mental and physical scores of the Medical Outcomes Study Short Form 36 at inclusion were independent determinants of positive and extreme costs in multivariate models.

CONCLUSION

WP loss is substantial in EA patients and is due to permanent disability before the third year of disease. Work absence and poor mental and physical health status at baseline are major determinants of WP costs.

Work disability and productivity loss in patients with inflammatory bowel diseases in Hungary in the era of biologics

BACKGROUND AND AIMS

To assess work disability (WD) rates in an inflammatory bowel disease (IBD) cohort involving patients with Crohn's disease (CD) or ulcerative colitis (UC) cohort and to identify possible clinical or demographic factors associated with WD. To our knowledge, this is the first study from Eastern Europe that has estimated indirect costs in IBD.

METHODS

Data from 443 (M/F: 202/241, CD/UC: 260/183, mean age: 35.5 (CD) and 40.5 (UC) years, biological drug exposure 31.2/11.5%) consecutive patients were included. WD data were collected by questionnaire and the work productivity and activity impairment instrument. Disability pension (DP) rates in the general population were retrieved from public databases.

RESULTS

The overall DP rate in this IBD population was 32.3%, with partial disability in 24.2%. Of all DP events, 88.8% were directly related to IBD. Overall, full DP was more prevalent in IBD (RR: 1.51, p < 0.001) and CD (RR: 1.74, p < 0.001) but not in UC compared to the general population and also in CD compared to UC (OR 1.57, p = 0.03). RR for full DP was increased only in young CD patients (RR<35 year olds: 9.4; RR36-40 year olds: 9.4 and 5.6, p < 0.01 for both). In CD, age group, previous surgery, disease duration, frequent relapses, and the presence of arthritis/arthralgia were associated with an increased risk for DP. Among employed patients, absenteeism and presenteeism was reported in of 25.9 and 60.3% patients, respectively, leading to a 28% loss of work productivity and a 32% activity loss, and was associated with disease activity and age group. Average cost of productivity loss due to disability and sick leave with a human capital approach was 1,450 and 430 €/patient/year in IBD, respectively (total productivity loss 1,880 €/patient/year), the costs of presenteeism were 2,605 (SD = 2,770) and 2,410 (SD = 2,970) €/patient/year in CD and UC, respectively.

CONCLUSION

Risk of DP was highly increased in young CD patients (sixfold to ninefold). Previous surgery and presence of arthritis/arthralgia was identified as risk factors for DP. Work productivity is significantly impaired in IBD and is associated with high productivity loss.

The personal and national costs of lost labour force participation due to arthritis: an economic study

BACKGROUND

The costs of arthritis to the individuals and the state are considerable.

METHODS

Cross-sectional analysis of the base population of Health&WealthMOD, a microsimulation model of 45 to 64 year old Australians built on data from the Australian Bureau of Statistics' Survey of Disability, Ageing and Carers and STINMOD, an income and savings microsimulation model.

RESULTS

Individuals aged 45 to 64 years who had retired early due to arthritis had a median value of AU$260 in total weekly income whereas those who were employed full time were likely to average more than five times this. The large national aggregate impact of early retirement due to arthritis includes AU$9.4 billion in lost GDP, attributable to arthritis through its impact on labour force participation.When looking at the ongoing impact of being out of the labour force those who retired from the labour force early due to arthritis were estimated to have a median value of total savings by the time they are 65 of as little as $300 (for males aged 45-54). This is far lower than the median value of savings for those males aged 45-54 who remained in the labour force full time, who would have an estimated $339,100 of savings at age 65.

CONCLUSIONS

The costs of arthritis to the individuals and the state are considerable. The impacts on the state include loss of productivity from reduced workforce participation, lost income taxation revenue, and increased government support payments - in addition to direct health care costs. Individuals bear the economic costs of lost income and the reduction of their savings over the long term.

Very early rheumatoid arthritis as a predictor of remission: a multicentre real life prospective study

BACKGROUND

To assess whether, in the real world of three early arthritis clinics, early referral could allow the best outcome, ie, remission, to be reached, and whether reaching the outcome was more dependent on therapy than on disease duration or vice versa.

METHODS

1795 patients with early arthritis (symptom duration≤12 months) were entered into a prospective follow-up study. 711 patients (39.6%) were diagnosed with rheumatoid arthritis (RA). Each RA patient was treated according to the local algorithm, in three tertiary referral centres (representing a small province, a medium sized province and a metropolitan area, respectively). Remission, defined using the disease activity score in 28 joints (DAS28<2.6) and American College of Rheumatology (ACR) criteria, was the major outcome evaluated at the 12-month follow-up.

RESULTS

DAS28 remission was achieved in 34.3% (range 19.5-49%) of RA patients and ACR remission in 15.2% (range 8.5-20.6%). At the multivariate logistic regression analysis only two variables emerged as predictors of the major outcome: being in very early rheumatoid arthritis (VERA; less than 12 weeks symptom duration at the time of first treatment) and being on disease-modifying antirheumatic drugs (DMARD) within 3 months from disease onset. Among RA patients in remission, only 10% of VERA subjects received an anti-TNF blocker compared with 32.2% of non-VERA patients (p=0.002, OR 0.23, 95% CI 0.09 to 0.64).

CONCLUSIONS

In a real-world setting, the 12 weeks disease duration and an early intervention with DMARD represent the most significant opportunities to reach the major outcome, ie, remission of RA. Moreover, VERA represents a window of opportunity in terms of cost saving.

Kinematic Analysis of Gait Following Intra-articular Corticosteroid Injection into the Knee Joint with an Acute Exacerbation of Arthritis

PURPOSE

The objective of this study was to examine the effects of intra-articular corticosteroid injection (ICI) on ipsilateral knee flexion/extension, ankle dorsiflexion/plantarflexion (DF/PF), and hip abduction/adduction (abd/add) during stance phase in people with an acute exacerbation of rheumatoid arthritis (RA) of the knee joint. The study also assessed the effects of ICI on spatiotemporal parameters of gait and functional status in this group.

METHODS

Nine people with an exacerbation of RA of the knee were recruited. Kinematic and spatiotemporal gait parameters were obtained for each participant. Knee-related functional status was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Spatiotemporal gait parameters and joint angles (knee flexion, ankle DF/PF, hip abd/add) of the affected side were compared pre- and post-ICI.

RESULTS

Data for eight people were available for analysis. Median values for knee flexion and ankle PF increased significantly following ICI. Gait parameters of cadence, velocity, bilateral stride length, bilateral step length, step width, double-support percentage, and step time on the affected side also showed improvement. Pain and knee-related functional status as measured by the KOOS showed improvement.

CONCLUSIONS

This study demonstrated a beneficial short-term effect of ICI on knee-joint movements, gait parameters, and knee-related functional status in people with acute exacerbation of RA of the knee.

Cost-effectiveness of adding magnetic resonance imaging to rheumatoid arthritis management

BACKGROUND

Early, aggressive treatment of rheumatoid arthritis (RA) improves outcomes but confers increased risk. Risk stratification to target aggressive treatment of high-risk individuals with early RA is considered important to optimize outcomes while minimizing clinical and monetary costs. Some advocate the addition of magnetic resonance imaging (MRI) to standard RA risk stratification with clinical markers for patients early in the disease course. Our objective was to determine the incremental cost-effectiveness of adding MRI to standard risk stratification in early RA.

METHODS

Using a decision analysis model of standard risk stratification with or without MRI, followed by escalated standard treatment protocols based on treatment response, we estimated 1-year and lifetime quality-adjusted life-years, RA-related costs, and incremental cost-effectiveness ratios (with MRI vs without MRI) for RA patients with fewer than 12 months of disease and no baseline radiographic erosions. Inputs were derived from the published literature. We assumed a societal perspective with 3.0% discounting.

RESULTS

One-year and lifetime incremental cost-effectiveness ratios for adding MRI to standard testing were $204,103 and $167,783 per quality-adjusted life-year gained, respectively. In 1-way sensitivity analyses, model results were insensitive to plausible ranges for every variable except MRI specificity, which published data suggest is below the threshold for MRI cost-effectiveness. In probabilistic sensitivity analyses, most simulations produced lifetime incremental cost-effectiveness ratios in excess of $100,000 per quality-adjusted life-year gained, a commonly cited threshold.

CONCLUSION

Under plausible clinical conditions, adding MRI is not cost-effective compared with standard risk stratification in early-RA patients.

The value of early intervention in RA--a window of opportunity

Rheumatoid arthritis (RA) is associated with progressive joint destruction, with functional status influenced by both disease activity and radiographic progression. The case for early aggressive treatment of RA is based on large amounts of good data in many countries. Studies with conventional disease-modifying anti-rheumatic drugs in early RA have shown improved outcomes compared with later treatment, especially if an aggressive approach with combinations of drugs is used. Early intervention with tumour necrosis factor (TNF) inhibitors has been shown to improve clinical outcomes, induce remission and prevent radiographic progression. It also improves patients' functional status, health-related quality of life, and reduces fatigue. Patients with RA have reduced productivity, an increased number of lost work days and retire early; enabling patients to work should be at the core of a therapy's cost-effectiveness. Introduction of anti-TNF therapy early in RA has been shown to decrease job loss and reduce the amount of working time missed. Although the drug costs of initial treatment with combination therapy including a TNF inhibitor are high, these may be compensated by the reduction in lost productivity, making such a strategy cost-effective overall. In addition, some patients who respond well to combination therapy may be able to stop the TNF inhibitor. It is important to assess the benefits of any intervention not just to healthcare costs but to society as a whole, and physicians should be advocates for optimal access to effective therapies for their patients.

Clinical and psychosocial factors associated with depression and anxiety in Singaporean patients with rheumatoid arthritis

AIM

To assess the frequency of, and factors associated with, depression and anxiety in Singaporean patients with rheumatoid arthritis (RA).

METHOD

One hundred RA patients were recruited in a cross-sectional study. Socio-demographics, severity of anxiety and depression, disease activity, levels of serological markers and health-related quality of life were analyzed.

RESULTS

Twenty-six percent presented with anxiety, 15% with depression and 11% with both. Univariate regression showed that age (P = 0.039), Disease Activity Scale (DAS-28) (P < 0.001), number of medications (P < 0.001) and rheumatoid factor (RF) (P < 0.001) were positively associated with severity of depression, while income (P = 0.001), education (P = 0.029), self-perceived social support (P = 0.007), Short form 12 (SF-12) physical health (P < 0.001) and SF-12 mental health (P < 0.001) were negatively associated with severity of depression. After adjustment for confounding factors in multivariate regression, income (β = -0.347, P = 0.018), RF (β = 0.304, P = 0.043) and SF-12 mental health (β = -0.501 P = 0.001) remained significantly associated with depression. Univariate regression showed that DAS-28 (P = 0.009), number of medications (P = 0.004) and RF (P = 0.043) were positively associated with anxiety, while income (P = 0.022), self-perceived social support (P = 0.04), SF-12 physical health (P < 0.001) and SF-12 mental health (P < 0.001) were negatively associated with anxiety. After adjustment for confounding factors, no factors remained significantly associated with anxiety.

CONCLUSION

Low income, high levels of RF and poor mental health were associated with depression in RA. Our findings may help to formulate depression screening strategies. Further research is required to identify the role of RF in depression.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

The significance of presenteeism for the value of lost production: the case of rheumatoid arthritis

Lost production can be due to individuals' time lost to work (absenteeism), as well as their time at work with reduced productivity because of ill health (presenteeism). A sound methodological framework for the assessment of presenteeism remains to be established but given its significance, ignoring it would lead to severe underestimations, eg, in cost-of-illness studies. The objective of this study was to assess the empirical significance of absenteeism and presenteeism in terms of production loss using the case of rheumatoid arthritis (RA). Selected modules from the Health and Labor Questionnaire were applied in a cross-sectional study of 3,704 patients with RA. The costs of absenteeism and presenteeism were estimated using the Human Capital approach, and the impact of including multipliers adjusting for the productivity effect of a workers' absence or impaired presenteeism on societal productivity was demonstrated. RA-related absenteeism over the last 14 days was 22.31 hours (standard deviation [SD], 26.51) with a resulting cost of €473 (SD, 575) and €762 (SD, 926) depending on whether a multiplier was included. Presenteeism was found to affect 7.98 (SD, 3.24) working days over the last 14 days with a resulting cost of €168 (SD, 203) and €203 (SD, 245), again depending on whether a multiplier was included. Overall, this article demonstrates that the value of lost production due to RA could be subject to an almost factor 2 increase if productivity effects of presenteeism and general multipliers are included.

Effect of certolizumab pegol with methotrexate on home and work place productivity and social activities in patients with active rheumatoid arthritis

OBJECTIVE

To assess the impact of certolizumab pegol (CZP), a novel PEGylated anti-tumor necrosis factor, in combination with methotrexate (MTX) on productivity outside and within the home, and on participation in family, social, and leisure activities in adult patients with rheumatoid arthritis (RA).

METHODS

The efficacy and safety of CZP (200 mg and 400 mg) plus MTX were assessed in 2 phase III, multicenter, double-blind, placebo-controlled trials (Rheumatoid Arthritis Prevention of Structural Damage [RAPID] 1 and RAPID 2). The novel, validated, RA-specific Work Productivity Survey (WPS-RA) was used to assess work place and home productivity. WPS-RA responses were collected at baseline and every 4 weeks until withdrawal/study completion.

RESULTS

At baseline, 41.6% and 39.8% of subjects were employed outside the home in RAPID 1 and RAPID 2, respectively. Compared with placebo plus MTX, CZP plus MTX significantly reduced work absenteeism and presenteeism among patients working outside the home. Significant reductions in number of household days lost, household days with productivity reduced by >/=50%, and days lost due to RA for participation in family, social, and leisure activities were reported by patients in active treatment relative to placebo plus MTX. Improvements in all measures were observed with CZP plus MTX as early as week 4, and maintained until the study end (12 months in RAPID 1, 6 months in RAPID 2). Findings were consistent with clinical improvements with CZP plus MTX in both trials.

CONCLUSION

CZP plus MTX improved productivity outside and within the home and resulted in more participation in social activities compared with placebo plus MTX. These observations suggest that considerable indirect cost gains might be achieved with this therapeutic agent in RA.

Assessing adequate treatment response in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) presents a substantial socioeconomic burden that is potentially reduced by individualized, appropriate management strategies. Integral to such strategies is recognizing the need for treatment changes when patients inadequately respond or do not respond to treatment. However, there might be little or no agreement as to what constitutes treatment failure or an adequate response. Currently used American College of Rheumatology response criteria and the disease activity score may underestimate the magnitude of treatment failure when applied in clinical practice, and, having been designed to differentiate responses between large groups, they may be of limited value in monitoring individual patients.

OBJECTIVE

The aim of this commentary was to assess how treatment failure and clinical remission/response have been defined in clinical studies.

METHODS

A PubMed search (1948-2009) was conducted to identify clinical studies or reviews containing the following search terms: rheumatoid arthritis and treatment failure, inadequate response, biologic therapy, DMARD, radiographic response, and remission. Select clinical reports in patients with RA were included if remission or treatment failure, radiographic or other, was a study end point.

RESULTS

Thirty-three studies were identified. The present assessment found no consensus as to what represents a practical definition of treatment failure or clinical remission in the clinical studies assessed. The definitions varied from the complete absence of any clinical disease to computer-generated numeric scales. The variability in clinical definitions of treatment failure or remission seems to have been mainly attributed to the time at which assessments were made, making it difficult to determine what treatment failure or remission means in individual patients with RA in clinical practice.

CONCLUSIONS

Based on the findings of the present commentary, standard definitions of treatment failure or clinical remission/response are needed. Aggressive treatment strategies with specific clinical goals may result in better long-term outcomes. Early evidence of treatment effect may serve to improve clinical outcomes, including remission, and help define and align treatment goals in patients with RA.

Cost of Finnish statutory inpatient rehabilitation and its impact on functional and work capacity of patients with early rheumatoid arthritis: experience from the FIN‐RACo trial

OBJECTIVE

To explore the cost of the statutory inpatient rehabilitation system in Finland and its impact on the functional and work capacity of patients with early rheumatoid arthritis (RA).

METHODS

In the Finnish Rheumatoid Arthritis Combination-Therapy trial (FIN-RACo), 195 patients with recent-onset RA, 162 of them available for the work force, were randomly assigned to two different drug treatment strategies for 2 years. Otherwise, the patients received routine multidisciplinary care and, if their functional or work capacity was endangered, were referred to inpatient rehabilitation. After a 5-year follow-up, data on rehabilitation, sick leave, and RA-related disability pensions were obtained from official registers.

RESULTS

Of the 162 patients, 49 (30%) underwent inpatient rehabilitation at an average cost of EURO5400. The rehabilitated patients more often worked in white-collar jobs and had more pain and a worse Health Assessment Questionnaire (HAQ) score (1.0 vs. 0.78; p = 0.01) at baseline. Their HAQ scores remained higher throughout follow-up (p<0.001); no change appeared over inpatient periods [mean 0.01; 95% confidence interval (CI) -0.13 to 0.16]. No independent impact of rehabilitation on the HAQ score emerged in an adjusted generalized estimating equations (GEE) model (p = 0.55). Nor did any improvement in work capacity appear: average lost productivity (human capital approach) per patient-year was EURO10 155 (95% CI 6994-14 196) before and EUR 12 839 (95% CI 8589-19 139) after the start of rehabilitation.

CONCLUSION

For patients with recent-onset RA, the Finnish statutory inpatient rehabilitation system had no positive impact on either functional or work capacity during the first few years, despite its considerable cost.

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.

Workplace impacts of anti-TNF therapies in rheumatoid arthritis: review of the literature

BACKGROUND

Rheumatoid arthritis (RA) causes pain and serious functional impacts and substantially affects patients' daily lives, including their ability to work.

OBJECTIVE

This review examines recent studies of patients with RA treated with TNF antagonists and the impacts these therapies have on the workplace.

METHODS

A total of 133 articles and 14 poster abstracts were reviewed that matched specific criteria.

RESULTS/CONCLUSION

The results of early studies of TNF antagonists varied regarding their effects on patients with RA in the workplace. However, recent studies of adalimumab showed positive impacts across a range of workplace burdens. Treatments such as adalimumab may help employees with RA to remain in the workforce and lead to reduced workplace costs to the employers and employees.

Sick leave before and after diagnosis of rheumatoid arthritis--a report from the Swedish TIRA project

OBJECTIVE

Our study describes sick leave during 3 years before and 3 years after diagnosis of rheumatoid arthritis (RA) in relation to referents and identifies predictors for sick leave during the third year after diagnosis of RA.

METHODS

One hundred twenty patients (76% women) from the Swedish early RA study TIRA were included. Disease activity and disability were registered regularly during 3 years in TIRA. Referents were matched for sex, age, and home town. Sick leave data were obtained for patients 3 years before and 3 years after diagnosis and for the referents for the corresponding 6 years.

RESULTS

No differences were seen between patients and referents regarding sick leave during the first 2 years, whereas sick leave increased in patients 6 months before diagnosis, from 30% to 53%. During the 3 years after diagnosis, sick leave among patients was rather stable, varying between 50% and 60%, even though disability pension increased and sickness benefit decreased. Sick leave before diagnosis, disability 1 year after diagnosis, and type of work were identified as predictors for sick leave during the third year after diagnosis.

CONCLUSION

Not surprisingly, sick leave in patients increased the year before diagnosis. Although disease activity and disability diminished after diagnosis, the patients' sick leave remained essentially unchanged. Sick leave 3 years after diagnosis was foremost predicted by earlier sick leave, disability, and type of work.

Women, men, and rheumatoid arthritis: analyses of disease activity, disease characteristics, and treatments in the QUEST-RA study

Introduction

Gender as a predictor of outcomes of rheumatoid arthritis (RA) has evoked considerable interest over the decades. Historically, there is no consensus whether RA is worse in females or males. Recent reports suggest that females are less likely than males to achieve remission. Therefore, we aimed to study possible associations of gender and disease activity, disease characteristics, and treatments of RA in a large multinational cross-sectional cohort of patients with RA called Quantitative Standard Monitoring of Patients with RA (QUEST-RA).

Methods

The cohort includes clinical and questionnaire data from patients who were seen in usual care, including 6,004 patients at 70 sites in 25 countries as of April 2008. Gender differences were analyzed for American College of Rheumatology Core Data Set measures of disease activity, DAS28 (disease activity score using 28 joint counts), fatigue, the presence of rheumatoid factor, nodules and erosions, and the current use of prednisone, methotrexate, and biologic agents.

Results

Women had poorer scores than men in all Core Data Set measures. The mean values for females and males were swollen joint count-28 (SJC28) of 4.5 versus 3.8, tender joint count-28 of 6.9 versus 5.4, erythrocyte sedimentation rate of 30 versus 26, Health Assessment Questionnaire of 1.1 versus 0.8, visual analog scales for physician global estimate of 3.0 versus 2.5, pain of 4.3 versus 3.6, patient global status of 4.2 versus 3.7, DAS28 of 4.3 versus 3.8, and fatigue of 4.6 versus 3.7 (P < 0.001). However, effect sizes were small-medium and smallest (0.13) for SJC28. Among patients who had no or minimal disease activity (0 to 1) on SJC28, women had statistically significantly higher mean values compared with men in all other disease activity measures (P < 0.001) and met DAS28 remission less often than men. Rheumatoid factor was equally prevalent among genders. Men had nodules more often than women. Women had erosions more often than men, but the statistical significance was marginal. Similar proportions of females and males were taking different therapies.

Conclusions

In this large multinational cohort, RA disease activity measures appear to be worse in women than in men. However, most of the gender differences in RA disease activity may originate from the measures of disease activity rather than from RA disease activity itself.

Difficulties in calculating productivity costs: work disability associated with borderline personality disorder

OBJECTIVES

In trial-based analyses, the Human Capital (HC) approach is currently applied alternately with and without the incorporation of productivity costs for persons who are work disabled at baseline of the trial. We call these methods HC-extended (HC(EXT)) and HC-limited (HC(LIM)), respectively. Aim of the paper is to compare productivity costs according to HC(EXT) with HC(LIM) and the Friction Cost (FC) method, in patients with Borderline Personality Disorder (BPD).

METHODS

Data were obtained from a multicenter randomized trial in The Netherlands, comparing two types of outpatient psychotherapy, Schema Focused Therapy (SFT, n = 44) versus Transference Focused Psychotherapy (TFP, n = 42) for BPD. Mean age was 31.7 for SFT and 29.5 for TFP. A cost-interview was administered every three months for three years, and once again after the fourth year. Productivity costs were calculated according to HC(LIM), HC(EXT) and FC. A nonparametric bootstrap resampling method was performed.

RESULTS

During the trial, the number of work-disabled patients increased for both treatments. Total productivity costs for HC(EXT) were higher than for HC(LIM) and FC. In addition, the incremental bootstrapped costs (TFP - SFT) pointed in the same direction for HC(LIM) (1168 Euro; 95% UI 4700 Euro, 7563 Euro) and FC (1206 Euro; -2835 Euro, 4844 Euro), but turned around for HC(EXT)(minus 1240 Euro; -9973 Euro, 7911 Euro). None of the increments were statistically significantly different from zero.

CONCLUSIONS

The classical and frequently discussed contrast between HC and FC is not the only difference when it concerns productivity costs. Whether or not including productivity costs for patients who are work-disabled at baseline can lead to contradictory conclusions.

Economic burden of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic autoimmune disease characterized by inflammatory arthritis in association with skin psoriasis (Ps). PsA may show a heterogeneous and variable clinical course, with involvement of peripheral and axial diarthrodial joints, periarticular structures such as entheses, as well as the skin and nails. Evidence is increasing that affected patients can have significant radiographic joint damage, functional impairment, reduced quality of life (QOL) and long-term work disability. The economic burden of PsA can be considerable. There is an increasing interest in pharmacoeconomic evaluations in PsA, driven mostly by the introduction of highly effective but expensive biologic agents, particularly inhibitors of the proinflammatory cytokine tumour necrosis factor (TNF)-alpha. Treatment with TNFalpha inhibitors results in not only substantial improvements in signs and symptoms of arthritis, but also improvements in all distinct sites of the disease, such as axial arthritis, dactylitis, enthesitis and skin disease. There is a dearth of published pharmacoeconomic evaluations in the field of PsA. The notable clinical efficacy of the TNFalpha inhibitors needs to be factored into a comprehensive assessment of their value. Further analyses are needed to optimize the use of the new biologic agents in PsA.

Photoacoustic tomography of carrageenan-induced arthritis in a rat model

Laser-based photoacoustic tomography (PAT), a novel, nonionizing, noninvasive, laser-based technology, has been adapted to the diagnosis and imaging of inflammatory arthritis. A commonly used adjuvant induced arthritis model using carrageenan was employed to simulate acute rheumatoid arthritis in rat tail joints. Cross-sectional photoacoustic images of joints affected by acute inflammation were compared to those of the control. The diameter of the periosteum and the optical absorption of intra-articular tissue were measured on each joint image. Significant differences were found on PAT imaging between the affected joints and the control for both variables measured, including enlarged periosteum diameter and enhanced intra-articular optical absorption occurring in the joints affected with carrageenan-induced arthritis. Anatomical correlation with histological sections of imaged joints and microMRI results verified the findings of PAT. This suggests that PAT has the potential for highly sensitive diagnosis and evaluation of pathologic hallmarks of acute inflammatory arthritis.

Risk factors for back pain-related loss of working time after surgery for lumbar disc herniation: a 5-year follow-up study

The aim of this study is to explore the occurrence and the risk factors of back-related loss of working time in patients undergoing surgery for lumbar disc herniation. One hundred and fifty-two gainfully employed patients underwent surgery for lumbar disc herniation. Two months postoperatively, those patients completed a self-report questionnaire including queries on back and leg pain (VAS), functional capacity (Oswestry disability index--ODI, version 1.0), and motivation to work. After 5 years, lost working time was evaluated by means of a postal questionnaire about sick leave and disability pensions. The cumulative number of back pain-related days-off work was calculated for each patient. All 152 patients, 86 men and 66 women, were prescribed sick leave for the first 2 months. Thereafter, 80 (53%) of them reported back pain-related sick leave or early retirement. A permanent work disability pension due to back problems was awarded to 15 (10%) patients, 5 men (6%) and 10 women (15%). Median number of all work disability days per year was 11 (interquartile range [IQR] 9-37); it was 9 days (IQR 9-22) in patients with minimal disability (ODI score 0-20) at 2 months postoperatively and 67 days (IQR 9-352) in those with moderate or severe disability (ODI > 20; P < 0.001). The respective means were 61, 29, and 140 days/year. Multivariate analysis showed ODI > 20, leg pain, and poor motivation to work to be the risk factors for extension of work disability. Results of the present study show that after the lumbar disc surgery, poor outcome in questionnaire measures the physical functioning (ODI) and leg pain at 2 months postoperatively, as well as poor motivation to work, are associated with the loss of working time. Patients with unfavourable prognosis should be directed to rehabilitation before the loss of employment.

Economic issues with new rheumatologic therapeutics

PURPOSE OF REVIEW

Pharmacoeconomic evaluations are increasingly important in all aspects of medicine. In rheumatology, such studies have become all the more relevant following the introduction of highly effective biologic agents. Brought to the clinic initially for the treatment of rheumatoid arthritis, biologic agents have found expanded indication in other rheumatic diseases.

RECENT FINDINGS

Building upon a long tradition in rheumatology, recent studies have updated and expanded upon the costs of various rheumatic diseases. These studies set the stage for determining the value of newer therapies. As a result of the chronic nature of rheumatic diseases, pharmacoeconomic evaluations must be carried out over sufficiently long time frames. Therefore, methodologic issues continue to be an area of ongoing discussion. Finally, ongoing studies have estimated the cost-effectiveness of novel rheumatologic therapies, in particular the inhibitors of tumor necrosis factor. These studies have shown that in several clinical circumstances, tumor necrosis factor inhibitors can indeed have an incremental cost-efficacy within the range of generally accepted medical interventions. While many of these studies focused on rheumatoid arthritis, there is growing interest in pharmacoeconomic evaluations in other rheumatic diseases.

SUMMARY

Pharmacoeconomic evaluations are crucial to the optimal use of new therapies in rheumatology.

Work disability in rheumatic diseases

PURPOSE OF REVIEW

To review developments in the literature concerning work disability in the rheumatic diseases.

RECENT FINDINGS

There have been three sets of studies to emerge in the last year. In the first, several studies analyze alternative research methods to document work disability. The second set uses qualitative methods to identify the specific factors that affect the decision to leave work. The third set analyzes interventions to reduce work disability.

SUMMARY

The quantitative and qualitative studies concur on the importance of flexible working conditions as an important, if not the most important risk factor for work disability in a diverse array of rheumatic diseases.

Acute polyarthritis

Arthritis is the most common cause of disability. Hence, prompt recognition and management of acute-onset polyarthritis are paramount to prevent progressive damage. When rheumatoid arthritis is considered as a prototypical example of polyarthritis, the stakes of early and accurate evaluation are evident. The challenge is in determining when undifferentiated polyarthritis ends and rheumatoid arthritis begins. This chapter reviews the evidence to help clinicians identify and manage patients who present with acute polyarticular inflammation.