Thoughts on health economics in rheumatoid arthritis

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

Objective.

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

Methods.

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

Results.

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

Conclusion.

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

Influence of rheumatoid arthritis-related morning stiffness on productivity at work: results from a survey in 11 European countries

The objective of this study was to evaluate the influence of morning stiffness on productivity at work and to estimate the work-related economic consequences of morning stiffness among patients with RA-related morning stiffness in 11 European countries. The original sample comprised 1061 RA patients from 11 European countries (Belgium, Denmark, Finland, France, Germany, Italy, Norway, Poland, Spain, Sweden and UK). They had been diagnosed with RA and experience morning stiffness three or more times per week. Data were collected by interviews. Women comprised 77.9 % of the sample, the average age was 50.4 years, and 84.3 % had RA diagnosed for more than 2 years. Overall costs of RA-related morning stiffness was calculated to be 27,712€ per patient per year, varying from 4965€ in Spain to 66,706€ in Norway. On average, 96 % of the overall production losses were attributed to early retirement, with a markedly lower level (77 %) in Italy than in other countries (p < 0.0001). The proportion of patients who reported retirement due to morning stiffness and productivity losses due to late work arrivals and working while sick showed considerable variation across the countries represented in the study. Overall, the average annual cost of late arrivals (0.8 % of the total costs) was approximately half of the costs attributed to sick leave (1.7 %) and working while sick (1.5 %). Morning stiffness due to RA causes significant production losses and is a significant cost burden throughout Europe. There seem to be notable differences in the impact of morning stiffness on productivity between European countries.

Impact of morning stiffness on working behaviour and performance in people with rheumatoid arthritis

Work disability remains a considerable problem for many patients with rheumatoid arthritis (RA). Morning stiffness is a symptom of RA associated with early retirement from work and with impaired functional ability. We aimed to explore the patient's perception of the impact of morning stiffness on the working life of patients with RA. A survey was conducted in 11 European countries. Patients of working age, with RA for ≥6 months and morning stiffness ≥3 mornings a week, were interviewed by telephone using a structured questionnaire. Responses were assessed in the total sample and in subgroups defined by severity and duration of morning stiffness and by country. A total of 1,061 respondents completed the survey, 534 were working, 224 were retired and the rest were, i.e. homemakers and unemployed. Among the 534 working respondents, RA-related morning stiffness affected work performance (47 %), resulted in late arrival at work (33 %) and required sick leave in the past month (15 %). Of the 224 retired respondents, 159 (71 %) stopped working earlier than their expected retirement age, with 64 % giving RA-related morning stiffness as a reason. There was a differential impact of increasing severity and increasing duration of morning stiffness on the various parameters studied. There were notable inter-country differences in the impact of RA-related morning stiffness on ability to work and on retirement. This large survey showed that from the patient's perspective, morning stiffness reduces the ability to work in patients with RA and contributes to early retirement.

Acceptability of less than perfect health states in rheumatoid arthritis: the patients' perspective

Some health problems are considered by many individuals as a 'normal' part of ageing. Our aim was to investigate whether patients with rheumatoid arthritis (RA) consider different types and levels of health losses as acceptable beyond a certain age. A multicenter cross-sectional survey was performed involving RA patients at the initiation of the first biological therapy. The EQ-5D and the Health Assessment Questionnaire Disability Index (HAQ-DI) questionnaires were used to describe domain-specific health states. Patients were asked to indicate for each domain from what age and onward (between ages 30 and 80 years in 10 year intervals) they considered moderate and severe problems acceptable or alternatively never acceptable. Seventy-seven RA patients (females 86%, mean age 50.3, disease duration 9.1 years) completed the questionnaire. Disease activity (DAS28), EQ-5D and HAQ-DI scores were mean 6.00 (SD 0.85), 0.35 (SD 0.36), 1.48 (SD 0.66), respectively. The majority of the patients considered age 70 and beyond as acceptable to have some health problems (EQ-5D: self-care 42%, pain/discomfort 34%, mobility 33%, usual activities 33%, anxiety/depression 27%), whilst at ages 30 and 40 as not acceptable. Severe health problems were mostly (57-69%) considered never acceptable, except the 'Usual activities' domain (acceptable from age 80 by 50.6%). The great majority of the patients (77-96%) were younger than what they indicated as the acceptability age limit. Similar results were found for the HAQ-DI. This small experimental study suggests that RA patients consider some health problems acceptable. This acceptability is age related and varies by health areas. Further larger studies are needed to explore explanatory variables and to compare with other diseases. Owing to the impact acceptability might have on RA patients' self-evaluation of current health state and decision-making, the topic deserves methodological improvement and further investigation.

Cost-effectiveness of biological therapy compared with methotrexate in the treatment for rheumatoid arthritis in Colombia

The objectives of the study are to develop a cost-effectiveness model comparing biological therapy (BT) with methotrexate (MTX) alone, in the treatment for rheumatoid arthritis (RA), combining clinical and quality-of-life data from international trials with local costs and local epidemiological data. We designed a six-month cycle Markov model with five functional states, based on Health Assessment Questionnaire, with patients initiating treatment in any of the predefined states, based on a sample of 150 local RA patients. Simulations ran for 10 and 20 years, and for the whole life span. Utilities, in quality-adjusted life years (QALY), were taken from international literature. Discount rate was 3 % for costs and utilities. We calculated direct and indirect costs using a combination of international and local data. Results are presented as incremental cost-effectiveness ratios (ICER). ICERs in euros per QALY were <euro>143,072 for 10 years; <euro>139,332 for 20 years; and <euro>137,712 for the whole life span. Total costs with MTX were lower than with BT, despite higher out of pocket, productivity, and complication costs. Under conventional thresholds, and for the "average" RA patient, BT would not be cost-effective in Colombia. BT compared to MTX provides more QALYs, but at a high cost. When ICERs were estimated for Colombia, BT would not be cost-effective. We propose different thresholds for different conditions, perhaps prioritizing chronic diseases that lead to disability.

Modelling cost-effectiveness of biologic treatments based on disease activity scores for the management of rheumatoid arthritis in Spain

Background. The objective of this simulation model was to assess the cost-effectiveness of different biological treatment strategies based on levels of disease activity in Spain, in patients with moderate to severe active RA and an insufficient response to at least one anti-TNF agent. Methods. Clinically meaningful effectiveness criteria were defined using DAS28 scores: remission and Low Disease Activity State (LDAS) thresholds. Monte-Carlo simulations were conducted to assess cost-effectiveness over 2 years of four biological sequential strategies composed of anti-TNF agents (adalimumab, infliximab), abatacept or rituximab, in patients with moderate to severe active RA and an insufficient response to etanercept as first biological agent. Results. The sequential strategy including etanercept, abatacept and adalimumab appeared more efficacious over 2 years (102 days in LDAS) compared to the same sequence including rituximab as second biological option (82 days in LDAS). Cost-effectiveness ratios showed lower costs per day in LDAS with abatacept (427 €) compared to rituximab as second biological option (508 €). All comparisons were confirmed when using remission criteria. Conclusion. Model results suggest that in patients with an insufficient response to anti-TNF agents, the biological sequences including abatacept appear more efficacious and cost-effective than similar sequences including rituximab or cycled anti-TNF agents.

How much is a reduction in morning stiffness worth to patients with rheumatoid arthritis?

OBJECTIVE

The aim of this study was to determine the monetary equivalent of the emotional and functional impact of morning stiffness (MS) in patients with rheumatoid arthritis (RA), using alternative valuing methods.

METHODS

Telephone interviews were conducted among 166 patients with RA to assess utility and clinical symptoms, including MS. Three standard economic methods were used: the human capital approach (HCA), marginal value of time (MVT), and willingness-to-pay (WTP).

RESULTS

The monetary equivalent of the impact of MS varied with the method used (from EUR 5.74 to EUR 17.87 per patient per day) and severity of MS (5-8-fold higher in patients with severe MS compared with mild MS). Patients placed considerable value on a reduction in duration and severity of MS. Patients with MS lasting an hour or more were willing to pay EUR 21.74/day to stop the symptom and EUR 10.63/day to halve the duration. Patients with severe MS were willing to pay EUR 47.86/day to stop the symptom and EUR 21.68/day to halve the severity.

CONCLUSIONS

The observed variation in the monetary equivalent of the impact of MS obtained with the three estimation methods indicates that the findings of studies using different valuing methods should not be compared directly. The study demonstrates that a reduction in MS is worth a considerable amount to patients with RA, particularly those with severe or prolonged MS. These findings suggest that clinical treatment decisions to improve patients' quality of life should also incorporate therapy that reduces MS.