Sociodemographic and health system factors associated with variations in hospitalization costs for rheumatic diseases in adults aged 45 years and older: A cross-sectional study of provincial health accounts in Jiangsu Province, China.

AIM: To report the cost of hospitalization and the associated risk factors for rheumatic diseases in middle-aged and elderly patients in China. METHODS: The study participants included inpatients from hospitals of various levels in the Jiangsu Province Health Account database in 2016. Participants were selected by using a multistage sampling method. Patients <45 years of age were excluded, and patients hospitalized for rheumatic diseases were identified according to the 10th edition of the International Classification of Diseases. Generalized linear models were used to analyze the sociodemographic characteristics related to the hospitalization costs of patients with rheumatic diseases. RESULTS: The study included 3696 patients. The average cost of hospitalization for patients with rheumatic diseases was USD 4038.63. Female sex, a long length of stay, age between 65 and 74 years, free medical care, not being covered by the Urban-Rural Residents Basic Medical Insurance, and a high hospital level were associated with high hospitalization costs. CONCLUSION: This study examined hospitalization costs and relevant influencing factors in middle-aged and elderly patients with rheumatic disease in China. Our findings are useful for further research on costs of disease and the economic evaluation of strategies to prevent rheumatic disease.

Potential Cost Implications of Mandatory Non-Medical Switching Policies for Biologics for Rheumatic Conditions and Inflammatory Bowel Disease in Canada.

In 2018, TNFα inhibitors were the highest cost drug class for Canadian public drug programs. In 2019, two Canadian provinces announced mandatory nonmedical switching policies in an attempt to reduce their costs by increasing biosimilar uptake. The national impact of similar policies across Canada is unknown. We conducted a cross-sectional analysis of monthly publicly funded prescription claims for infliximab, etanercept, and adalimumab between June 2015 and December 2019. We reported the market share of biosimilars for infliximab and etanercept in 2019 for each province and estimated the cost savings that public payers could have realized in 2019 if mandatory switching policies had been implemented across Canada, including a sensitivity analysis, which assumed that governments receive a 25% rebate on all biologics. Provincial drug programs spent CAD $991.84 million on infliximab, etanercept, and adalimumab in 2019, and, when biosimilars were available, they constituted only 15.5% of national utilization of these drugs. In British Columbia, the implementation of a mandatory switching policy for patients with rheumatic conditions increased the biosimilar market share of infliximab and etanercept by 299% (from 19.7% to 78.5%). If applied nationwide to all three biologics for all indications, we estimate such policies could lead to annual savings of between CAD $179.71 million and CAD $425.64 million nationally. The overall market share of biosimilars remains low in all provinces where mandatory switching policies have not been introduced. The cost implications of successfully increasing biosimilar uptake would be substantial, particularly as more biosimilars reach the Canadian market.

Treatment Delays Associated With Prior Authorization for Infusible Medications: A Cohort Study.

OBJECTIVE: Prior authorizations (PAs) are commonly used by health payers as cost-containment strategies for expensive medications, including infused biologics. There is scarce data about the effect of PA requirements on patient-oriented outcomes. METHODS: We included patients for whom an infusible medication was prescribed for a rheumatologic condition. The exposures of interest were a PA requirement and whether or not the PA was denied. The primary outcome was the difference in days from medication request to infusion. Secondary outcomes included the proportion of denied PAs and differences in glucocorticoid exposure following a PA request. RESULTS: Of the 225 patients, the infusible medications of 160 (71%) required a PA. PAs were associated with a greater number of days to infusion compared to cases in which no authorization was required (median 31 days [interquartile range (IQR) 15-60 days] versus median 27 days [IQR 13-41 days]; P = 0.045), especially among the 33 patients (21%) whose PA was denied initially (median 50 days [IQR 31-76 days] versus median 27 days [IQR 13-41 days]; P < 0.001). PA denials were associated with greater prednisone-equivalent glucocorticoid exposure in the 3 months following the request than when a PA was not required (median 605 mg [IQR 0-1,575] versus median 160 mg [IQR 0-675]; P = 0.01). Twenty-seven of the 33 PA requests that were initially denied (82%) were eventually approved. Thus, 96% of all PAs were ultimately approved. CONCLUSION: PA requirements are associated with treatment delays and denials are associated with greater glucocorticoid exposure. Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be reevaluated.

Are There Benefits and Risks to Biosimilars from a Patient Perspective?

Biosimilars are copies of biologic medications, which no longer are protected by patent, that are intended to be marketed at lower prices than their reference products to increase patient access to treatment. Because a biosimilar must have equivalent pharmacokinetic parameters and efficacy and comparable safety and immunogenicity with its reference product, the only significant difference between the two should be cost. Lower-priced biosimilars are intended to introduce market competition. The availability of biosimilars should yield savings for the health care system and improve treatment outcomes by expanding patient access to effective medications. However, patients should partake of these cost savings.

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

AIM: This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India. METHOD: The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self-reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection. RESULTS: 3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE-10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8-11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE-10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India. CONCLUSION: Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.

A Systematic Review of Productivity in Economic Evaluations of Workplace Interventions: A Need for Reporting Criteria?

BACKGROUND: Rheumatic and musculoskeletal diseases (RMDs) are understood to reduce levels of paid productivity. Productivity, including absenteeism and presenteeism, is arguably an important factor for consideration in economic evaluations of workplace interventions for RMDs (WPI-RMDs). Existing methods available to quantify and value absenteeism and presenteeism are heterogeneous and produce estimates that vary substantially across studies. To date, there has been no systematic summary of the reporting quality of methods used to quantify paid productivity included in economic evaluations of WPI-RMDs. OBJECTIVE: The aim of this systematic review was twofold. First, the review was conducted to understand if, and how, the impact of WPI-RMDs on productivity was considered and incorporated in published economic evaluations. Second, we aimed to assess the reporting quality of productivity in published economic evaluations of WPI-RMDs and determine the need for a published set of reporting guidelines for productivity. METHODS: This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic review published in 2008 that focused on the cost effectiveness of WPIs, with limited information on productivity, was updated from 2007 to July 2018. A global search was conducted using three online databases: MEDLINE (1946 to August 2018, week 2), EMBASE (1974 to 10 July 2018); and EconLit (1886 to July 2018). The studies were double-screened by four independent reviewers. Data extraction was conducted using a bespoke data extraction table. RESULTS: Twenty-one economic evaluations of WPI-RMDs were identified. All studies evaluated absenteeism, but only five reported on levels of presenteeism. The methods used to identify and measure absenteeism were fairly consistent; however, methods used to identify and measure presenteeism, and value absenteeism and presenteeism, varied across studies. Two studies may have potentially double-counted productivity in their economic evaluations of WPI-RMDs. The results of this systematic review identified key elements potentially useful as a starting point to inform reporting quality guidelines for productivity. CONCLUSIONS: Variation in the methods used to quantify productivity and how it is reported in economic evaluations suggests the need for specific published reporting guidelines for productivity. The development of standardised reporting guidelines for the identification, measurement, and valuation of absenteeism and presenteeism in economic evaluations may help reduce variation in the methods and promote transparency.

The Effect of Pre-Appointment Consultation Triage on Patient Selection and Revenue Generation in a University Rheumatology Practice.

OBJECTIVE: To evaluate the effectiveness of pre-appointment consult screening to identify patients with autoimmune and inflammatory rheumatic disease (AIRD) and to evaluate the revenue implications of routine outpatient care of patients with AIRD compared to that of non-AIRD patients. METHODS: Using data in the electronic medical records, we retrospectively analyzed all new outpatients who were referred for rheumatology consults during a 9-month period for a final diagnosis and revenue generation for routine outpatient care over 1 year following the consult review or initial evaluation. RESULTS: A total of 961 patients were referred to the outpatient rheumatology clinic and underwent pre-appointment triage. Overall, 673 patients were approved for evaluation of AIRD, and 288 patients were denied rheumatology consultation. Patients were seen an average of 13 days after the consult review. Among patients who were approved for consult, 597 came for evaluation, with 357 diagnosed as having an AIRD and 240 with a non-AIRD. Among patients who were denied a consult, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD (consult triage sensitivity 98%, positive predictive value 60%). The consult triage system allowed more AIRD patients to be seen over a 1-year period. Revenue data for outpatient care was available for 318 of 357 patients with an AIRD and 192 of 240 non-AIRD patients and showed that care for patients with an AIRD generates 44 times more revenue compared to care for non-AIRD patients ($5,877 per AIRD patient versus $134 per non-AIRD patient; P < 0.001). CONCLUSION: Pre-appointment consult screening is an effective method to identify patients with an AIRD. This approach enables timely access to care for patients with the highest need for evaluation and results in significantly more revenue generation.

Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: relevance, need, and processes for development.

Guidelines or recommendations help to provide uniform standards in medical practice. The development of guidelines requires adherence to pre-defined norms prescribed by different international organizations such as the European League against Rheumatism (EULAR). We searched Pubmed and LILACS to identify published papers in five major rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, osteoarthritis, and scleroderma) from different countries based on their economic prosperity and could find a lack of published literature from most economically weaker regions. Similarly, published guidelines in these rheumatic diseases were sparse from Asia and Africa, which are economically developed to a lesser extent than other regions of the world. Considering differing economic realities driving patient care in different regions of the world, unique challenges in certain geographic areas such as musculoskeletal manifestations of infectious diseases like leprosy and tuberculosis, as well as distinct risk of malignancies and other comorbid conditions, National Rheumatology societies should work towards developing more guidelines for rheumatic diseases from regions such as Asia and Africa, while following strictly the prescribed norms for the same. With a paucity of guidelines for such regions currently, an alternative (although less preferable) suggestion would be that major international societies, whose guidelines are widely read and followed the world over, should consider inputs from experts from diverse regions of the world while developing these guidelines.

Socio-economic inequalities in occurrence and health care costs in rheumatic and musculoskeletal diseases: results from a Spanish population-based study including 1.9 million persons.

OBJECTIVES: To explore and compare the impact of socio-economic deprivation on the occurrence of the major rheumatic and musculoskeletal diseases (RMDs) and health care costs. METHODS: Data on diagnoses, socio-demographics and health care costs of the entire adult population of the Basque Country (Spain) was used. Area deprivation index included five categories (1 to 5 (most deprived)). Cost categories included primary and specialist care, emergency room, hospitalisations, and drug prescriptions. Twenty-nine RMDs were grouped into seven groups: Rheumatoid Arthritis, Spondyloarthritis, Crystal Arthropathies, Osteoarthritis, Soft Tissue Diseases, Connective Tissue Diseases, and Vasculitis. The relations between the deprivation and the occurrence of RMD and costs were explored in regression models adjusted for relevant confounders. RESULTS: Data from 1,923,156 adults were analysed. Mean age was 49.9 (SD18.4) years, 49% were males. Soft tissue diseases were the most prevalent RMD (5.5%, n=105,656), followed by osteoarthritis (2.2%, n=41,924). Socio-economic deprivation was associated with higher likelihood to have any of the 29 RMDs. The strongest socio-economic gradient was seen for the soft tissue diseases (OR 1.82 [95%CI 1.78;1.85], most vs. least deprived), followed by osteoarthritis (OR 1.59 [1.54;1.64]). Deprivation was also associated with higher costs across the majority of the conditions however patterns were more blurred, and inverse relationship was observed for connective tissue diseases, gout, hip osteoarthritis and undifferentiated (poly)arthritis. CONCLUSIONS: Socio-economic deprivation is associated with increased occurrence of all RMDs, and in most cases more deprived patients incur higher health care costs.

Clinical and economic implications of upper gastrointestinal adverse events in Asian rheumatological patients on long-term non-steroidal anti-inflammatory drugs.

AIM: To determine the incidence and direct costs of NSAID-induced upper GI adverse events in Malaysian rheumatology patients. METHODS: A retrospective, multi-centre, cohort study of rheumatology patients on long-term NSAIDs was conducted. Clinical data of patients treated between 2010 and 2013 were collected for a 24-month follow-up period. The costs of managing upper GI adverse events were based on patient level resource use data. RESULTS: Six hundred and thirty-four patients met the inclusion criteria: mean age 53.4 years, 89.9% female, diagnosis of rheumatoid arthritis (RA; 59.3%), osteoarthritis (OA; 10.3%) and both RA and OA (30.3%). Three hundred and seventy-one (58.5%) patients were prescribed non-selective NSAIDs and 263 (41.5%) had cyclo-oxygenase-2 inhibitors. Eighty-four upper GI adverse events occurred, translating into a risk of 13.2% and an incidence rate of 66.2 per 1000 person-years. GI adverse events comprised: dyspepsia n = 78 (12.3%), peptic ulcer disease (PUD) n = 5 (0.79%) and upper GI bleeding (UGIB) n = 1 (0.16%). The total direct healthcare cost of managing adverse events was Malaysian Ringgit (MR) 37 352 (US dollars [USD] 11 419) with a mean cost of MR 446.81 ± 534.56 (USD 136.60 ± 163.42) per patient, consisting mainly of GI pharmacotherapy (33.8%), oesophagoduodenoscopies (23.1%) and outpatient clinic visits (18.2%). Mean cost per patient by GI events were: dyspepsia, MR 408.98 ± 513.29 (USD125.03 ± 156.92); PUD, MR 805.93 ± 578.80 (USD 246.39 ± 176.95); UGIB, MR 1601.94 (USD 489.74, n = 1). CONCLUSION: The economic burden of GI adverse events due to long-term NSAIDs use in Malaysian patients with chronic rheumatic diseases is modest.

Productivity Losses and Costs in the Less-Common Systemic Autoimmune Rheumatic Diseases.

PURPOSE OF REVIEW: We synthesised the literature on productivity losses and costs in the less-common systemic autoimmune rheumatic diseases: Sjogren's syndrome (SjS), systemic sclerosis (SSc), poly/dermatomyositis (PM/DM), and systemic vasculitides (SV). RECENT FINDINGS: Of 29 studies located, 12 were published 2012 onwards (SSc = 6, SjS = 2, PM/DM = 2, SV = 2). In these, 25% of PM/DM, and 21-26% of SV, were work disabled, 22% of SSc stopped work within 3 years of diagnosis, and annual costs of absenteeism in SSc averaged $12,024 2017 USD. Very few studies reported on costs, presenteeism (working at reduced levels), or unpaid productivity loss. Across multiple systemic autoimmune rheumatic diseases (SARDs), major drivers of lost productivity were generalised items like pain, depression, and fatigue, rather than disease-specific factors. Evidence suggests that work disability is common in SSc and strikes quickly. However, in SSc and other SARDs, more comprehensive estimates are needed, which include absenteeism and presenteeism from paid and unpaid work, costs, and drivers of productivity loss.

Socioeconomic burden of pain in rheumatic disease.

Socioeconomic inequities in the health outcomes of rheumatic diseases, including pain, have been well documented across countries and study designs. Nevertheless, health disparities remain surprisingly-poorly understood in the rheumatic diseases, owing both to the complex nature of those disorders, and to methodological challenges surrounding the evaluation of social class and of its ties to health. Methodological difficulties in measuring SES can complicate interpretation of results to understand mechanisms of these associations. Current research on associations between SES and pain in rheumatic diseases are summarised in this article. Our review indicates that inequalities in pain in patients with OA and RA with low individual SES are strong and well-established, although associations in other rheumatic conditions and with community or childhood SES are less well-established. Further, the range of proposed mechanisms underlying disparities is broad, encompassing numerous indicators of SES, such as occupation, income, and education and varying widely by disease.

Second-line treatment persistence and costs among patients with immune-mediated rheumatic diseases treated with subcutaneous TNF-alpha inhibitors.

The objective of this study was to describe treatment persistence with second-line subcutaneous tumor necrosis factor-alpha inhibitors (SC-TNFis) in patients with immune-mediated rheumatic diseases (IMRDs) in Sweden, and the impact of non-persistence on healthcare costs. This retrospective observational study was based on Swedish national health register data. Adults were identified through filled prescriptions for adalimumab (ADA), etanercept (ETA), certolizumab pegol (CZP) and golimumab (GLM). Persistence was estimated over 3 years for propensity score-matched (PSM) cohorts using non-parametric survival analysis. Unadjusted comparisons of costs comprised specialized outpatient care, inpatient care, and medication. In total, N = 845 patients were identified and three PSM cohorts were generated (GLM vs. ADA, ETA, and CZP, respectively). GLM exhibited higher persistence than ADA over the study period (p = 0.040), and numerically higher persistence than ETA and CZP for 36 and 30 months, respectively. Persistent and non-persistent patients had similar mean total cost at 12 month pre-treatment ($5185 vs. $5064, p = 0.750). During the 12 month post-treatment initiation, persistent patients had lower mean total costs ($4377 vs. $6605), corresponding to a cost difference of $2228 (p < 0.001). In second-line treatment with SC-TNFis for IMRDs in Sweden, GLM exhibited significantly higher persistence than ADA over the course of the study. Similarly, GLM showed numerically higher persistence than ETA and CZP, which is concurrent with results observed in first-line SC-TNFi treatment. Considering the lower healthcare costs for persistent patients, the choice of second-line SC-TNFi among eligible patients may merit careful consideration given its impact on patients and payers.

Filling the gaps in SARDs research: collection and linkage of administrative health data and self-reported survey data for a general population-based cohort of individuals with and without diagnoses of systemic autoimmune rheumatic disease (SARDs) from British Columbia, Canada.

PURPOSE: Systemic autoimmune rheumatic diseases (SARDs) are a group of debilitating autoimmune diseases, including systemic lupus erythematosus and related disorders. Assessing the healthcare and economic burden of SARDs has been challenging: while administrative databases can be used to determine healthcare utilisation and costs with minimal selection and recall bias, other health, sociodemographic and economic data have typically been sourced from highly selected, clinic-based cohorts. To address these gaps, we are collecting self-reported survey data from a general population-based cohort of individuals with and without SARDs and linking it to their longitudinal administrative health data. PARTICIPANTS: Using administrative data from the province of British Columbia (BC), Canada, we established a population-based cohort of all BC adults receiving care for SARDs during 1996-2010 (n=20 729) and non-SARD individuals randomly selected from the general population. BC Ministry of Health granted us contact information for 12 000 SARD and non-SARD individuals, who were recruited to complete the surveys by mail or online. FINDINGS TO DATE: Four hundred individuals were initially invited to participate, with 135 (34%) consenting and 127 (94%) submitting the first survey (72% completed online). Sixty-three (49.6%) reported ≥1 SARD diagnosis. The non-SARDs group (n=64) was 92% female with mean age 57.0±11.6 years. The SARDs group (n=63) was 94% female with mean age 56.5±13.1 years. Forty-eight per cent of those with SARDs were current-or-former smokers (mean 10.6±16.2 pack-years), and 33% were overweight or obese (mean body mass index of 24.4±5.3). FUTURE PLANS: Health and productivity data collected from the surveys will be linked to participants' administrative health data from the years 1990-2013, allowing us to determine the healthcare and lost productivity costs of SARDs, and assess the impact of patient-reported variables on utilisation, costs, disability and clinical outcomes. Findings will be disseminated through scientific conferences and peer-reviewed journals.

Defining Quality of Rheumatologic Care: Mexico.

We present an overview of rheumatology practices in Mexico, describing the national health care system as segmented and fragmentary, with a population separated into 3 main categories, according to employment-based coverage and income level: (1) private sector, (2) Social Security System, and (3) public insurance subsector.The rheumatology practice in the public and private sectors are described. We estimate that between 85%-90% of Mexican rheumatologists have a mixed (public and private)-type practice. Payments to rheumatologists are not currently affected by quality and value metrics, with low penetrance of electronic health records. Recent changes and challenges to health insurance coverage are illustrated.

Biopharmaceuticals: Reference Products and Biosimilars to Treat Inflammatory Diseases.

Biopharmaceuticals are primarily therapeutic proteins developed to perform specific functions by acting on the disease pathophysiology. Compared with low-molecular chemically synthesized drugs, production of biopharmaceuticals is much more complex and routes of administration and pharmacokinetics differ. Biopharmaceuticals are blockbusters in the treatment of inflammatory diseases, such as psoriasis, multiple sclerosis, rheumatic diseases, and inflammatory bowel diseases, and the introduction of these drugs has revolutionized treatment. Disadvantages include their high costs and the fact that they can evoke antidrug antibodies leading to decreased efficacy. Treatment can be optimized through the development of dosing algorithms and cost can be reduced by biosimilars, after a comparable biological activity, safety, and efficacy have been demonstrated.

The Corrona US registry of rheumatic and autoimmune diseases.

The Corrona US national registry collects data concerning patient status from both the rheumatologist and patient at routine clinical encounters. Corrona has functioning disease registries in rheumatoid arthritis, psoriatic arthritis, spondyloarthropathies, psoriasis and inflammatory bowel disease. Corrona merges data concerning long-term effectiveness and safety, as well as comparative and cost effectiveness of agents to treat these autoimmune diseases.