OP0156-HPR COST EFFECTIVENESS OF TELE-HEALTH FOLLOW-UP IN RHEUMATOID ARTHRITIS BASED ON A NON-INFERIORITY RANDOMIZED CONTROLLED TRIAL

Background:

The clinical effectiveness of a patient-reported outcome (PRO) based telehealth intervention offered to rheumatoid arthritis (RA) patients with low disease activity or remission has previously been reported1. The TeRA study showed that PRO-based telehealth follow-up in RA achieved similar disease control as conventional outpatient follow-up among patients with low disease activity or remission. The degree of disease control did not differ between telehealth follow-up offered by rheumatologists or rheumatology nurses.

Objectives:

To compare the cost-effectiveness of PRO–based telehealth follow-up to patients with RA performed by rheumatologists or rheumatology nurses with conventional outpatient follow-up.

Methods:

A total of 294 patients were randomized (1:1:1) to either PRO-based telehealth follow-up carried out by a nurse (PRO-TN) or a rheumatologist (PRO-TR), or conventional outpatient follow-up by physicians. Quality of life (EQ-5D) was measured at baseline and at follow-up after one year. The primary outcome was a change in the Disease Activity Score, C-reactive Protetin in 28 joints (DAS-28, CRP).

The focus in the health economic evaluation was on the relation between costs and EQ-5D in the period between one year prior to and one year after the intervention. All costs were measured at the individual level and consisted of: intervention costs, health and social care costs, and productivity costs. All cost data were retrieved from Danish population-based registers. Incremental cost-effectiveness rates (ICERs) were calculated on the basis of a comparison of the development in costs and effects in the two intervention groups (separately and combined) with the control group. Bootstrap with 10,000 replications were used to access significance.

Results:

The difference in health and social care costs during the intervention period compared to the year before were €1,072, - €50 and €519 for the control group, the PRO-TR group and the PRO-TN respectively. Hence, the change in health and social care costs was lower for both intervention groups. The PRO-TR group had a small decrease and it was significantly lower than for the control group (p=0.0027). The difference between health and social care costs in the PRO-TN group compared to the control group was only borderline significant (p=0.067). No statistically significant differences were found in QALY’s between the three groups, all three groups experienced minor, non-significant, declines in QALY over the intervention period. ICER’s were not statistically significant but below known threshold values for the PRO-RN group (ICER=€17,121).

Conclusion:

It is difficult to obtain statistically significant results for cost-effectiveness in small samples. However, the results point towards a possible cost-saving impact of PRO interventions in patients with low disease activity or remission. The study was unable to conclude if PRO-TR or PRO-TN were most cost-effective. Other relevant considerations, like patient satisfaction or organisational issues, should determine the way of organizing RA disease management in these patients.

References:

[1]de Thurah A, Stengaard-Pedersen K, Axelsen M, et al. Tele-Health Follow-up Strategy for Tight Control of Disease Activity in Rheumatoid Arthritis: Results of a Randomized Controlled Trial.Arthritis care & research2018;70(3): 353-60.

Disclosure of Interests:

Annette de Thurah Grant/research support from: Novartis (not relevant for the present study)., Speakers bureau: Lily (not relevant for the present study)., Christian Skovsgaard: None declared, Thomas Maribo: None declared, Niels Henrik Hjøllund: None declared, Marie Kruse: None declared

Prevalence of Coxiella burnetii in women exposed to livestock animals, Denmark, 1996 to 2002

Binary file ES_Abstracts_Final_ECDC.txt matches

Using infertile patients in epidemiologic studies on subfecundity and embryonal loss

Subfecundity is a frequent and serious problem that may sometimes be preventable, but we need to know more about its determinants. Different epidemiologic designs are available. The best of these use prospectively collected data from the population, but they are time consuming, expensive and often hampered by low-participation rates. Most patients undergoing infertility treatment are closely monitored for clinical reasons, making it feasible to use secondary data to study the period from conception to implantation and pregnancy. In spite that infertility patients are highly selected, there are specific exposure-effect relations that can be studied in cohorts of infertility patients. These patients offer a potentially useful setting for studying exposures that operate late in fertilization, whereas the designs may be inadequate to identify exposures that cause reduced sperm counts, anovulation and total occlusion. The clinical sampling and the treatment set limitations for what can be studied. In certain situations, infertile patients can, however, provide useful epidemiologic evidence for learning about the causes of subfecundity.

[Stress and fertility. A follow-up study among couples planning the first pregnancy]

Mental distress has often been suggested as a cause of unexplained infertility. However, the causal direction may well be from infertility to distress, and prospective data are needed. We therefore followed 393 couples, who were planning their first pregnancy, with prospective collection of information on distress from termination of birth control until pregnancy for a maximum of six menstrual cycles. The analyses included 1,475 menstrual cycles, and mental distress was measured in each cycle by the General Health Questionnaire (GHQ). Urine samples from each period of vaginal bleeding were analyzed for human chorionic gonadotrophic hormone, indicating early embryonal loss. We found that for cycles with the highest distress score (GHQ score above the 80 percentile) the probability of conception per cycle was 12.8% compared to 16.5% in other cycles (adjusted OR 0.6; 95% CI 0.4-1.0). The effect of distress was almost exclusively found among women with long menstrual cycles (OR 0.1; 95% CI 0.01-0.4 and OR 0.9; 0.5-1.4 for women with cycles > or = 35 and < 35 days, respectively). An increased incidence of early embryonal loss was also found among highly distressed women with long cycles, but was based on a small number of observations. It is concluded that psychological distress may be a risk factor for reduced fertility in women with long menstrual cycles.

Birthweight and semen characteristics

A correlation between birthweight and sperm counts in adult life was anticipated because impaired fetal growth could impair replication of Sertoli cells produced in fetal life. Furthermore, it was expected that males born with a high birthweight might have impaired sperm production as they are expected to have been exposed to higher levels of oestrogen in fetal life. We examined these predictions by including midwives records for 296 Danish males that had taken part in studies on male fecundity for other reasons. The study provided no support for these expectations. If anything, males born with a birthweight of 3000-3999 g had slightly lower sperm counts and more abnormal spermatozoa.

[Semen quality and fertility in a population-based follow-up study]

Little is known about the importance of semen quality in male infertility. We followed 430 first pregnancy planners with no previous reproductive experience recruited among more than 50,000 cohabiting trade-union members. The couples were consecutively enrolled into the study as they discontinued contraception and were followed up for six month menstrual cycles or until a pregnancy was verified. Each man provided a semen sample at enrollment. Women kept daily record of vaginal bleeding and sexual activity. The probability of conception increased with increasing sperm concentration up to 40 x 10(6)/ml, but any higher sperm density was not associated with additional likelihood of pregnancy. The proportion of sperm with normal morphology was strongly related to likelihood of pregnancy, independently of sperm concentration. In conclusion, sperm concentration and morphology are valuable biological markers of male fecundity. Reference values for semen quality based on biological knowledge can be established.

Zinc, magnesium and calcium in human seminal fluid: relations to other semen parameters and fertility

The effects of zinc, magnesium and calcium in seminal plasma on time-to-pregnancy (TTP) in healthy couples, on conventional semen parameters and computer-assisted semen analysis (CASA) parameters were evaluated. The localization of chelatable zinc ions in seminal plasma and spermatozoa were assessed by autometallography (AMG). Differences in chelatable zinc localization in samples with high and low total zinc were evaluated. Semen samples from 25 couples with short TTP and 25 couples with long TTP were subjected to conventional semen analysis, CASA, zinc and magnesium measurements by inductively coupled plasma mass spectrometry, and calcium by flame atomic absorption spectrometry. The cations were strongly inter-correlated, but no correlation with TTP or conventional semen parameters was found. Semen samples with high zinc concentrations exhibited statistically significant poorer motility assessed by the CASA parameters straight line velocity and linearity than samples with low zinc content. Calcium concentration also showed statistically significant differences for the same parameters, but the effect was removed by entering zinc concentration into a multiple regression model. Semen samples with high total zinc exhibited stronger staining of the seminal plasma at AMG. It is suggested that high seminal zinc concentrations have a suppressing effect on progressive motility of the spermatozoa ('quality of movement'), but not on percentage of motile spermatozoa ('quantity of movement').

Menstrual cycle pattern and fertility: a prospective follow-up study of pregnancy and early embryonal loss in 295 couples who were planning their first pregnancy

OBJECTIVE

To characterize how the menstrual cycle pattern relates to fertility regardless of potential biases caused by inappropriate coital timing during the menstrual cycle or early embryonal loss.

DESIGN

Prospective follow-up study.

SETTING

Healthy couples recruited throughout Denmark.

PATIENT(S)

Two hundred ninety-five couples who were planning their first pregnancy were followed up from the discontinuation of birth control until a pregnancy was recognized within six menstrual cycles. Early embryonal losses were detected by changes in urinary hCG levels.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The probability of pregnancy occurring within one menstrual cycle (fecundity).

RESULT(S)

In women who had a cycle length that differed by >10 days from the usual cycle length, fecundity was approximately 25% that of women who had no variation (odds ratio 0.25, 95% confidence interval 0.09-0.68). When the combined effect of cycle variation and cycle length was assessed, cycle variation was a persistent strong predictor of fecundity.

CONCLUSION(S)

The mechanisms of the present findings probably are female functional disturbances in ovulation, conception, implantation, or sustained pregnancy, linked with variable menstrual cycle length. Thus, identification of medical and environmental causes of abnormal menstrual cycle patterns may provide clues to the causes of infertility. Moreover, the menstrual cycle pattern also should be taken into consideration in the clinical decision-making process.

[Information on previous spontaneous abortions in the Medical Birth Registry]

The reliability of information concerning previous spontaneous abortions in the Danish Medical Birth Register was evaluated by a historical follow-up study based on existing registers. The material consisted of data from the Medical Birth Register, the National Patient Register and the Central Person Register concerning 567 women who each had had at least two deliveries during the period 1978-1987. The number of previous abortions registered in the Birth Register at the first and last delivery during the period was compared with the number of hospital-treated abortions identified in the National Patient Register in the period between the two deliveries. Fifty-one women reported a greater number of spontaneous abortions to the Birth Register at the second delivery than at the first. In 57% this was in accordance with the diagnoses registered in the National Patient Register, incorrect reporting of a provoked abortion was a possibility in 16%. Thirty-five women were registered in the National Patient Register as having been treated in hospital for one or more spontaneous abortions. This agreed with the information in the Birth Register in 83% of the cases. Of 80 women who reported at least one spontaneous abortion at the first delivery 23% reported a lower number at the last delivery. It is concluded that the Danish Medical Birth Register's data on previous spontaneous abortions is only partly in agreement with the information contained in the National Patient Register. The difference can partly be explained by spontaneous abortions not treated in hospitals, but the agreement is lower than that of self-administered questionnaires. Misclassification between spontaneous and provoked abortion presumably occurs frequently.

[Can the carpal tunnel syndrome be work-related?]

The carpal tunnel syndrome is the most commonly reported nerve entrapment syndrome. While a number of medical risk factors are wellknown, accounting for approximately 25% af the cases, the significance of repetitive occupational hand strain has been disputed during several decades. Recently, a number of controlled epidemiological studies concerning this issue have emerged. A critical review arrives at the conclusion that jobs requiring highly repetitive and forceful sustained hand activity are associated with an increased risk for the carpal tunnel syndrome. The risk is, in particular, high when both risk factors are involved concomitantly. Exposure to hand-arm vibration also increases the risk, but it is undecided whether vibration per se or the associated ergonomic strain is the causal factor. It is argued that the evidence is sufficient to justify worker compensation and action should be taken to prevent this work-related disorder.