Examining the relationship between rheumatoid arthritis, multimorbidity and adverse health-related outcomes: A systematic review protocol

Multimorbidity status and annual healthcare expenditures of rheumatoid arthritis patients: a Dutch hospital-centered versus population-based comparison

The prevalence of multimorbidity among rheumatoid arthritis (RA) patients is increasing and associated with worse outcomes. Therefore, management of multimorbid patients requires a multidisciplinary approach. However, healthcare systems consist of mono-disciplinary subsystems, which limits collaboration across subsystems. To study the importance of a multidisciplinary, integrated approach, associations between expenditures and multimorbidity are assessed in real-life data. Retrospective data on RA patients from a Dutch single-hospital are analyzed and compared to the Dutch RA population data. The Elixhauser index is used to measure the multimorbidity prevalence. Regression analyses were conducted to derive the relationship between multimorbidity, healthcare costs and self-reported quality of life (e.g. EQ-5D). When analyzing the impact of multimorbidity within RA patients in context of a single-hospital context, multimorbidity is only partially captured: 13% prevalence versus 24% of the Dutch population. Multimorbidity is associated with higher care expenditures. Depending on the type of multimorbidity, expenditures are €43-€5821 higher in a single-hospital and from €2259-€9648 in population data. Finally, medication use associated with chronic diseases and self-reported aspects of well-being are associated with similar increases in healthcare expenditures as multimorbidity based on hospital care. Within RA, a single-hospital approach underestimates the association between multimorbidity and healthcare expenditures as 43% of healthcare utilization and expenditures are missed. To overcome a single-provider perspective in healthcare and efficiently coordinate multimorbid patients, besides providing holistic care, professionals also need to use data providing comprehensive pictures of patients.

Frailty in rheumatoidrmdopen-2021-002111 arthritis and its relationship with disease activity, hospitalisation and mortality: a longitudinal analysis of the Scottish Early Rheumatoid Arthritis cohort and UK Biobank

OBJECTIVE

To assess the prevalence of frailty in rheumatoid arthritis (RA) and its association with baseline and longitudinal disease activity, all-cause mortality and hospitalisation.

PARTICIPANTS

People with RA identified from the Scottish Early Rheumatoid Arthritis (SERA) inception cohort (newly diagnosed, mean age 58.2 years) and UK Biobank (established disease identified using diagnostic codes, mean age 59 years). Frailty was quantified using the frailty index (both datasets) and frailty phenotype (UK Biobank only). Disease activity was assessed using Disease Activity Score in 28 joints (DAS28) in SERA. Associations between baseline frailty and all-cause mortality and hospitalisation was estimated after adjusting for age, sex, socioeconomic status, smoking and alcohol, plus DAS28 in SERA.

RESULTS

Based on the frailty index, frailty was common in SERA (12% moderate, 0.2% severe) and UK Biobank (20% moderate, 3% severe). In UK Biobank, 23% were frail using frailty phenotype. Frailty index was associated with DAS28 in SERA, as well as age and female sex in both cohorts. In SERA, as DAS28 lessened over time with treatment, mean frailty index also decreased. The frailty index was associated with all-cause mortality (HR moderate/severe frailty vs robust 4.14 (95% CI 1.49 to 11.51) SERA, 1.68 (95% CI 1.26 to 2.13) UK Biobank) and unscheduled hospitalisation (incidence rate ratio 2.27 (95% CI 1.45 to 3.57) SERA 2.74 (95% CI 2.29 to 3.29) UK Biobank). In UK Biobank, frailty phenotype also associated with mortality and hospitalisation.

CONCLUSION

Frailty is common in early and established RA and associated with hospitalisation and mortality. Frailty in RA is dynamic and, for some, may be ameliorated through controlling disease activity in early disease.

The use and context of the term 'multimorbidity' in rheumatoid arthritis: a systematic literature review

This systematic literature review aimed to analyse terms describing coexisting conditions in the RA literature, informing the need for an operationalized definition of multimorbidity. Articles discussing RA with multimorbidity, published 1946 until August 2020, were identified. The primary outcome was the use and/or definition of 'multimorbidity' in RA. Information extracted included terms defining coexisting conditions, the use of a comorbidity/multimorbidity score and the use of 'index disease' to describe RA (more applicable to comorbidity than multimorbidity). Thirty-nine articles were included. Eight articles used the term 'multimorbidity', 18 used 'comorbidity' and 12 used both terms, 7 synonymously. One used no term. Fourteen articles fully defined the term. The number of co-existing conditions described in included studies was one-121. Twelve articles used a comorbidity/multimorbidity score. Four articles described RA as the 'index disease'. Our results demonstrate inconsistent use of the term multimorbidity. Improved assessment of multimorbidity is indicated in RA patients, including an operationalized use and definition.

Examining the relationship between rheumatoid arthritis, multimorbidity and adverse health-related outcomes: a systematic review

OBJECTIVE

Multimorbidity (the co-existence of two or more long-term conditions (LTCs)) is highly prevalent in people with rheumatoid arthritis (RA). This work systematically reviewed the literature to determine the effect of multimorbidity on all-cause mortality, functional status and quality of life in RA.

METHODS

Six electronic databases were searched: CINAHL, Cochrane Library, Embase, Medline, PsycINFO and Scopus. Full-text longitudinal observational studies in English were selected. Quality appraisal of studies was undertaken using the Cochrane-developed QUIPS tool and a narrative synthesis of findings conducted.

RESULTS

5,343 papers were identified by the search strategy, with 19 studies meeting the inclusion criteria. Nine studies had mortality as an outcome, nine reported functional status and/or quality of life and one study reported both mortality and functional status. The number of participants ranged from 183-18,485, with studies conducted between 1985-2018. Mean age of participants ranged from 53.5-66.6 years; with 60.0-84.2% female. Nine studies reported a significant association between multimorbidity and higher risk of mortality in people with RA. Ten studies reported significant associations between multimorbidity and reduced functional status in RA. Three studies also reported a further association with reduced quality of life. Only one study investigated the influence of mental health comorbidities on outcomes.

CONCLUSION

Our review findings indicate that multimorbidity is a significant predictor for higher mortality and poorer functional status/quality of life in people with RA and should be considered in clinical management plans.