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.

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.

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.

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.

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.

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.

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.

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.

Pharmacoeconomics of Biosimilars: What Is There to Gain from Them?

Despite representing a breakthrough in the treatment of immune-mediated rheumatic diseases, the direct costs of biotechnological therapies represent a burden to healthcare budgets worldwide. Furthermore, several studies demonstrated that socioeconomically constrained countries have poorer access to these therapies and this has consequences on the optimal management of rheumatic patients. Experience with small peptide biosimilars like filgrastim and epoetin confirmed significant cost savings but revealed variable market uptake. In this report, we summarize the available budget impact models and discuss possible determinants of the pharmacoeconomic performance of antirheumatic biosimilar drugs.

Treatment persistence among patients with immune-mediated rheumatic disease newly treated with subcutaneous TNF-alpha inhibitors and costs associated with non-persistence.

The main objective of this study was to describe real-world treatment persistence with subcutaneous tumor necrosis factor-alpha inhibitors (SC-TNFi) in patients with ankylosing spondylitis, psoriatic arthritis, or rheumatoid arthritis [collectively immune-mediated rheumatic disease, (IMRD)] in Sweden. A secondary objective was to describe potential effects on health care resource utilization (HCRU) cost from non-persistence. Patients were identified through filled prescriptions for adalimumab (ADA), etanercept (ETA), certolizumab pegol (CZP), and golimumab (GLM) between 5/6/2010 and 12/31/2012 from the Swedish Prescribed Drug Register. Persistence was estimated using survival analysis. Costs were derived from HCRU and comprised specialized outpatient care, inpatient care and non-disease-modifying antirheumatic drug medications. A total of 4903 patients were identified (ADA: 1823, ETA: 1704, CZP: 622, GLM: 754). Comparisons over 3 years showed that GLM had significantly higher persistence than ADA (p = 0.022) and ETA (p = 0.004). The mean difference in non-biologic HCRU costs between persistent and non-persistent patients was higher after compared to before the start of biologic therapy. SC-TNFi-naïve IMRD patients initiating treatment with GLM had significantly higher persistence rates than patients initiating treatment with ADA or ETA in Sweden. Furthermore, persistence rates observed in the study were lower than those observed in clinical trials, highlighting the need for an all-party (provider-patient-payer-drug manufacturer) engagement and development of programs to increase persistence rates in clinical practice, thus leading to improved clinical outcomes. In addition, the results of this study indicate that persistence to treatment with SC-TNFi may be associated with cost offsets in terms of non-biologic costs.

The economic impact of early retirement attributed to rheumatic diseases: results from a nationwide population-based epidemiologic study.

OBJECTIVES: To measure early retirement due to self-reported rheumatic diseases (RDs) and to estimate the respective indirect costs and years of working life lost (YWLL). METHODS: We used individual level data from the national, cross-sectional, population-based EpiReumaPt study (September 2011-December 2013) where 10,661 inhabitants were randomly surveyed in order to capture and characterize all cases of RD within a representative sample of the Portuguese population. In this analysis, we used all participants aged between 50 and 64 years, near the official retirement age. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. YWLL were estimated as the difference between each participant's current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. We also calculated the percentage of time in inactivity (inactivity ratio = YWLL/Active age-range [15-64 years old]). RESULTS: 29.9% of the Portuguese population with ages between 50 and 64 years were retired with 13.1% self-reporting retirement due to RD. The estimated annual indirect cost following premature retirement attributed to RD was €910 million (€555 per capita; €1625 per self-reported RD patient and €13,592 per early retiree due to RD). Females contributed with 84% for these costs (€766 million; €882 per capita vs €187 from males). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. RD patients with higher values of disability have the highest risk of early retirement. CONCLUSIONS: Early retirement attributed to self-reported RD amounts to approximately 0.5% of the national gross domestic product (GDP) in 2013, due to large YWLL. Both the public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

[Characteristics and challenges of rheumatology-specific laboratories in practice]. / Besonderheiten und Herausforderungen des spezifischen Rheumalabors in der Praxis.

In Germany rheumatological laboratory investigations are increasingly being carried out by rheumatologists in private practice. The professional and economic value is shown in association with the historical development of laboratory medicine and the current discussion on vocational politics.

Indirect costs associated with early exit from work attributable to rheumatic diseases.

BACKGROUND: Rheumatic diseases (RD) cause physical disability that may lead to early exit from work, generating indirect costs to society. We aimed to measure these costs in a population approaching the statutory retirement age. METHODS: The analysis was based on the prevalence of self-reported RD using a bottom-up approach. Health and sociodemographic data were retrieved from the fourth National Health Survey (INS), for all people between 50 and 64 years of age (3762 men and 4241 women), whereas an official national database was used to estimate productivity values by gender, age group and region, using the human capital approach. The effects of RD on the likelihood of early exit from paid employment and the attributable fractions estimates were obtained at the individual level by logistic regression. RESULTS: At the time of the survey, 37.2% of the population aged 50-64 years self-reported at least one RD. Among these, 52.6% were not employed, compared with 40.7% of those without RD (P < 0.001). The annual indirect costs following premature exit from work attributable to RD were €650 million (€892 per RD patient). Early retirement amounted to €367 million, whereas early retirement and unemployment totalized €385 million (€504 and €528 per RD patient, respectively). Females are responsible for about 60% of these costs; however, males contribute with higher individual productivity losses. CONCLUSION: Early exit from work attributable to RD amounts to approximately 0.4% of the national GDP. The public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

Embitterment in patients with a rheumatic disease after a disability pension examination: occurrence and potential determinants.

OBJECTIVES: Health care and vocational professionals regularly encounter patients with rheumatic diseases who are embittered after a disability pension examination. People who are embittered typically feel victimised, experience resentment and injustice, resist help, and have difficulty coping. Our objective was to examine the occurrence of embitterment in patients with rheumatic diseases after a disability pension examination and the association of embitterment with its possible determinants helplessness and illness invalidation at work. METHODS: The Illness Cognition Questionnaire (ICQ), Illness Invalidation Inventory (3*I), and Bern Embitterment Inventory were completed by patients who had 9 to 12 weeks earlier received the result of a disability pension examination. Diagnoses were fibromyalgia (n=103), rheumatoid arthritis (n=46), osteoarthritis (n=158), another rheumatic disease (n=62), and more than one rheumatic disease (n=187). Scores were compared to scores of reference groups. Hierarchical regression analyses were conducted. RESULTS: Eighteen to 27 percent of patients had high levels of embitterment with no differences between diagnostic groups (p=0.71). Helplessness (p<0.001), the two invalidation dimensions discounting and lack of understanding (p<0.001), and the combination of helplessness with these invalidation dimensions (p<0.01), were predictive of more embitterment. CONCLUSIONS: Our results suggest that, after a disability pension examination, embitterment is present in about one out of five patients with a rheumatic disease. This is problematic insofar as embitterment limits well-being, functioning, and the potential to reintegrate to work. To the extent that helplessness and invalidation at work are causal determinants of embitterment, interventions targeting these aspects may be key to reduce embitterment.

Biosimilars: how similar?

As patents expire on biological agents for the treatment of rheumatic diseases, we have the opportunity to develop non-proprietary biologic agents, biosimilars. The development and approval of these agents present novel challenges to both pharma and regulatory agencies although there is great promise of high quality, less expensive biologic agents for the treatment of rheumatic diseases. Here, we review the definitions of biosimilars, the regulatory challenges to approval of these agents and the record of approvals of biosimilars to date.

Evaluation of a structured goal planning and tailored follow-up programme in rehabilitation for patients with rheumatic diseases: protocol for a pragmatic, stepped-wedge cluster randomized trial.

BACKGROUND: Comprehensive rehabilitation, involving health professionals from various disciplines, is widely used as an adjunct to pharmacological and surgical treatment in people with rheumatic diseases. However, the evidence for the clinical- and cost-effectiveness of such interventions is limited, and the majority of those who receive rehabilitation are back to their initial health status six to 12 months after discharge. METHODS/DESIGN: To evaluate the goal attainment, health effects and cost-effectiveness of a new rehabilitation programme compared to current traditional rehabilitation programmes for people with rheumatic diseases, a stepped-wedge cluster randomized trial will be performed. Patients admitted for rehabilitation at six centres in the south-eastern part of Norway will be invited to participate. In the trial, six participating centres will switch from a control (current rehabilitation programme) to an intervention phase (the new rehabilitation programme) in a randomized order. Supported by recent research, the new programme will be a supplement to the existing programme at each centre, and will comprise four elements designed to enhance and support lifestyle changes introduced in the rehabilitation period: structured goal-planning, motivational interviewing, a self-help booklet and four follow-up telephone calls during the first five months following discharge. The primary outcome will be health-related quality of life and goal attainment, as measured by the Patient Generated Index directly before and after the rehabilitation stay, as well as after six and 12 months. Secondary outcomes will include self-reported pain, fatigue, a global assessment of disease activity and motivation for change (measured on 11-point numeric ratings scales), health-related quality of life as measured by the Short Form 36 Health Survey (SF-36) and utility assessed by the SF6D utility index.The main analysis will be on an intention to treat basis and will assess the clinical- and cost-effectiveness of the structured goal planning and tailored follow-up rehabilitation programme for patients with rheumatic diseases. DISCUSSION: The findings will constitute an important contribution to more cost-effective- and evidence-based rehabilitation services for people with rheumatic diseases. TRIAL REGISTRATION: ISRCTN91433175.

[Biosimilars in rheumatology and other fields of medicine]. / Rola biosymilarów w reumatologii i innych dziedzinach medycyny.

Biosimilars are follow-up versions of innovative medicines with proved high similarity to the reference product. There may be some minor differences in clinically inactive components of a molecule which can be clinically significant, but they do not substantially affect the high resemblance to the original drug in their safety and potency. Introduction of the biosimilars brings hope to reduce the cost of treatment, so their availability will increase further as the expiration of patents on biotechnologically produced drugs will follow, which is currently taking place. There are new biosimilar drugs being introduced recently; these are monoclonal antibodies. They are much more structurally complicated compared to the first biotech drugs such as insulin, and their production processes are much more complex. Biosimilars as the end products of such sophisticated technology are affected by many variables. It is not possible to create "biogenerics," but only biosimilar drugs. Therefore, despite their similarities to the reference molecules, biosimilars are too different to forego clinical trials. Clinical trials of biosimilars need to be much broader than for generics, but they are limited compared to the reference biologicals' testing. Placebo controlled clinical trials are not required before registering a new biosimilar. Immunogenicity is a major source of concern related to biosimilars, although there may be the same problem with the original drugs.

[Trends of work force participation of patients with rheumatic diseases : results from German social insurance data and the national database of the German collaborative arthritis centers]. / Trends der Erwerbstätigkeit von Rheumakranken : Ergebnisse aus Sozialversicherungsdaten und Kerndokumentation der Rheumazentren in Deutschland.

Positive therapeutic effects on the work force participation derived from international clinical trials may not be directly transferable to the community based care in Germany. Therefore recent changes of data regarding sick leave (SL), work disability pension (WDP) and employment from the social insurance and from the national database of the German collaborative arthritis centers were analyzed covering a time period of at least 10 years. Health insurance data showed a steeper decline in the average duration of SL caused by rheumatoid arthritis (RA), ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) compared with all other diseases. In RA patients from the collaborative arthritis centers the mean duration of SL was much more reduced than the average duration of SL for members of the compulsory health insurance. The proportion of gainfully employed RA patients in collaborative arthritis centers has particularly increased in women. According to data from the pension insurance fund less incident cases of WDP due to RA, AS, and SLE have been observed than WDP caused by all other diseases. Thus different nationwide data show positive changes of the work force participation of individuals suffering from inflammatory rheumatic diseases in Germany.

Costs of pain in rheumatology.

Chronic pain has been identified as an important issue related to various rheumatic diseases. At the time of a major government spending review, it is appropriate to discuss the pain characterising rheumatic diseases and its related costs. It is clearly essential for healthcare authorities to rationalise their policies on the basis of the increasing expectations of the users of healthcare services while simultaneously balancing their books. There are few published studies concerning the costs of pain of any kind, and the same is true of the costs of the chronic pain associated with diseases such as rheumatoid arthritis, osteoarthritis, and fibromyalgia.