Cost-of-illness of rheumatoid arthritis and ankylosing spondylitis

OBJECTIVES:\ud To assess, quantify and summarise the cost of illness of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) from the societal perspective.\ud \ud METHODS:\ud Original studies reporting costs of RA or AS were searched systematically. Both cost-of-illness studies and economic evaluations of therapies were included. Studies were appraised for patient and study characteristics, type of costs and actual costs. Reported costs were aggregated by cost categories and overall mean costs were summarised by cost domain (healthcare, patient and family, and productivity costs).\ud \ud RESULTS:\ud Overall mean costs of RA (€14,906 per year) were above that of AS (€9,374 per year), while the relative distribution of costs over cost domains was approximately similar. For both diseases, productivity costs based on the human cost approach were 3 to 10 times higher than the friction costs and accounted for more than half the total costs of both diseases.\ud \ud CONCLUSIONS:\ud Productivity costs constitute the largest part of the total cost-off-illness of RA and AS reflecting the high burden of the disease on work participation. Although total and direct costs of illness in RA were higher than in AS, the average age of AS patients was 10 years lower and therefore, lifetime costs associated with AS may actually be equal or higher

Cost-effectiveness of Spa treatment for fibromyalgia: general health improvement is not for free

Objectives: To estimate the cost-effectiveness of an adjuvant treatment course of spa treatment compared with usual care only in patients with fibromyalgia syndrome (FM). - \ud Methods: 134 patients with FM, selected from a rheumatology outpatient department and from members of the Dutch FM patient association were randomly assigned to a 2½ week spa treatment course in Tunisia or to usual care only. Results are expressed as quality-adjusted life years (QALYs) for a 6-month as well as a 12-month time horizon. Utilities were derived form the Short Form 6D (SF-6D) scores and the visual analogue scale (VAS) rating general health. Costs were reported from societal perspective. Mean incremental cost per patient and the incremental cost utility ratio (ICER) were calculated; 95% confidence intervals (CIs) were estimated using double-sided bootstrapping. -\ud Results: The data of 128 (55 spa and 73 controls) of the 134 patients (96%) could be used for analysis. Improvement in general health was found in the spa group until 6 months of follow-up by both the SF-6D (AUC 0.32 vs 0.30, P<0.05) and the VAS (AUC 0.23 vs 0.19, P<0.01). After 1yr no significant between-group differences were found. Mean incremental cost of spa treatment was E1311 per patient (95% CI 369–2439), equalling the cost of the intervention (thalassotherapy including airfare and lodging), or E885 per patient based on a more realistic cost estimate. -\ud Conclusions: The temporary improvement in quality of life due to an adjuvant treatment course of spa therapy for patients with FM is associated with limited incremental costs per patient

Modern psychometrics applied in rheumatology - a systematic review

Background Although item response theory (IRT) appears to be increasingly used within health care research in general, a comprehensive overview of the frequency and characteristics of IRT analyses within the rheumatic field is lacking. An overview of the use and application of IRT in rheumatology to date may give insight into future research directions and highlight new possibilities for the improvement of outcome assessment in rheumatic conditions. Therefore, this study systematically reviewed the application of IRT to patient-reported and clinical outcome measures in rheumatology. Methods Literature searches in PubMed, Scopus and Web of Science resulted in 99 original English-language articles which used some form of IRT-based analysis of patient-reported or clinical outcome data in patients with a rheumatic condition. Both general study information and IRT-specific information were assessed. Results Most studies used Rasch modeling for developing or evaluating new or existing patient-reported outcomes in rheumatoid arthritis or osteoarthritis patients. Outcomes of principle interest were physical functioning and quality of life. Since the last decade, IRT has also been applied to clinical measures more frequently. IRT was mostly used for evaluating model fit, unidimensionality and differential item functioning, the distribution of items and persons along the underlying scale, and reliability. Less frequently used IRT applications were the evaluation of local independence, the threshold ordering of items, and the measurement precision along the scale. Conclusion IRT applications have markedly increased within rheumatology over the past decades. To date, IRT has primarily been applied to patient-reported outcomes, however, applications to clinical measures are gaining interest. Useful IRT applications not yet widely used within rheumatology include the cross-calibration of instrument scores and the development of computerized adaptive tests which may reduce the measurement burden for both the patient and the clinician. Also, the measurement precision of outcome measures along the scale was only evaluated occasionally. Performed IRT analyses should be adequately explained, justified, and reported. A global consensus about uniform guidelines should be reached concerning the minimum number of assumptions which should be met and best ways of testing these assumptions, in order to stimulate the quality appraisal of performed IRT analyses

Patient participation in decision making about Disease Modifying Anti-Rheumatic Drugs:perceived and preferred roles of patients

Purpose: This study explores what role patients with rheumatic diseases perceive and prefer to have in decisions about Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and what the concordance between preferred and perceived role in these decisions is. Method: Patients (n = 519) diagnosed with Rheumatoid Arthritis, Arthritis Psoriatica or Ankylosis Spondylitis from 2 hospitals in the Netherlands filled out a questionnaire. Questions included perceived and preferred role in medical decision making in general, and in 4 specific decision-categories: starting to use traditional DMARDs, starting to inject a DMARD, starting to use biological DMARDs and decrease or stop using DMARDs. Result: Most respondents perceived that, in current practice, treatment decisions in general were made by the doctor (43%) or by the doctor and patient together (55%). However, the perceived roles varied per decision category: e.g., most patients (72%) felt that the decision to start using a traditional DMARD was made by the doctor, whereas the decision to decrease or stop using DMARD’s was more often perceived as being made by the patients themselves (24%) or by doctor and patient together (38%). The preferred roles were, contrary to the perceived roles, consistent across the decision-categories. Most respondents (59%-63%) preferred to share decisions with their doctor. By using a paired sample t test the concordance between the perceived and preferred role was evaluated. Table 1 shows that there was a significant difference in 4 of 5 decision categories. Only the decision to decrease or stop using DMARDs had no significant difference between perceived and preferred role. For a considerable group, the perceived and preferred participation for decision making in general matched (61%); about one third (29%) perceived less participation than preferred and a minority perceived more participation than preferred. Again, the concordance varied across the decision categories. Especially for the decision to start with a traditional DMARD, many respondents had experienced less participation than they preferred (54%). Conclusion: Although patients seem consistent in their preference for participation in various DMARD decisions, the amount of perceived participation varied across the different decisions. Patients should especially be more involved in decisions about starting to use a traditional DMARD. Patient Decision aids might be helpful tools to increase patient participation

Self-esteem in patients with rheumatic diseases:The role of body-self unity

Background: Maintaining positive self-esteem is one of the challenges for patients with chronic diseases. Limitations in physical functioning, often associated with having a rheumatic disease, can influence the perception of the body as belonging to the person (or as detached from the self) and might thereby finally affect the self-esteem of patients. The concept of body-self unity has been investigated in a phenomenological research tradition that works with qualitative methodology and small samples. Objectives: To develop a questionnaire to measure body-self unity quantitatively and to investigate the predictive value of body-self unity for self-esteem in patients with rheumatic diseases. Methods: The Body Experience Questionnaire was developed for the measurement of body-self unity. Besides this questionnaire, illness cognitions, pain intensity, functional limitations and self-esteem were measured via computers with touchscreen. 168 patients (mean age = 54,2 years, 62% female) with a rheumatic disease participated in this study consecutive visiting the rheumatology clinic. To analyse predictors of self-esteem, hierarchical regression analyses were employed (first step demographic characteristics, second step disease related variables (disease duration, functional limitations, pain), final step psychological constructs (body-self unity, illness cognitions)). Results: The Body Experience Questionnaire revealed a two factor structure with good reliability (subscale harmony, Cronbachs alpha=.76; subscale alienation, Cronbachs alpha = 0.84). The final model of the hierarchical regression analyses showed that self-esteem can be predicted by helplessness, acceptance, harmony of body and self and most strongly by the alienation of body and self. R2 of the final model was 0.50 (delta R for psychological variables in the final step was 0.28). The relation between functional limitations and self-esteem was fully mediated by the psychological constructs body self unity and illness cognitions. Conclusion: This study showed the importance of psychological characteristics and particularly the experience of the body for self-esteem in patients with a rheumatic disease. Further research should explore therapies to increase the body-self unity

Spa treatment for primary fibromyalgia syndrome: a combination of thalassotherapy, exercise and patient education improves symptoms and quality of life

Objectives: To study the effect of a combination of thalassotherapy, exercise and patient education in people with fibromyalgia. -\ud Methods: Patients with fibromyalgia, selected from a rheumatology out-patient department and from members of the Dutch fibromyalgia patient association, were pre-randomized to receive either 2 weeks of treatment in a Tunisian spa resort, including thalassotherapy, supervised exercise and group education (active treatment) or treatment as usual (control treatment). Primary outcome measure was health-related quality of life, measured with the RAND-36 questionnaire. Secondary measures included the Fibromyalgia Impact Questionnaire, the McGill Pain Questionnaire, the Beck Depression Inventory, tender point score and a 6-min treadmill walk test. -\ud Results: Fifty-eight participants receiving the active treatment reported significant improvement on RAND-36 physical and mental component summary scales. For physical health, differences from the 76 controls were statistically significant after 3 months, but not after 6 and 12 months. A similar pattern of temporary improvement was seen in the self-reported secondary measures. Tender point scores and treadmill walk tests improved more after active treatment, but did not reach significant between-group differences, except for walk tests after 12 months. -\ud Conclusions: A combination of thalassotherapy, exercise and patient education may temporarily improve fibromyalgia symptoms and health-related quality of life

Dutch rheumatologists and oncologists are positive about health-related Internet us by their patients

Background: An increasing number of patients are using the Internet to search for health-related information. Objectives: To explore the experiences and attitudes of rheumatologists and oncologists with regard to health-related Internet use by their patients. In addition, we explored how often physicians referred their patients to health-related Internet sites. Methods: We sent a questionnaire to all Dutch rheumatologists and oncologists. The questionnaire included questions on demographics, experiences with health-related Internet use by patients, referral behavior and attitudes about consequences of health-related Internet use by patients for patients themselves, the physician-patient relationship and health care. The response rate was 46% (N=238). Of these respondents 134 were in practice as a rheumatologist and 104 were in practice as an oncologist. Results: Almost all physicians encountered that patients raised information from the Internet during a consultation. However, physicians were not confronted with health-related Internet use by their patients on a daily basis. Physicians had a moderately positive attitude towards the consequences of health-related Internet use. The physicians indicated that patients are often better informed about their illness (54%) and often better informed about treatment options (51%) as a result of Internet use. According to the physicians, a negative consequence of health-related Internet use was that patients are more often unnecessarily concerned. Physicians felt that health-related Internet use by patients could sometimes (48%) or often (30%) lead to patients being more capable in participating in the decision making process concerning their treatment. Although 43% of physicians indicated that health related Internet use did almost never or usually not lead to better treatment decisions, many physicians (41%) indicated that sometimes health-related Internet use can lead to better treatment decisions. Most of the physicians indicated that health-related Internet use is usually not (46%) or almost never (23%) undermining the physicians' authority. The physicians indicated that unnecessary diagnostics and unnecessary treatments were often not provided as a result of Internet use by patients. Physicians indicated that the duration of a medical consultation sometimes (39%) or often (36%) increases because of health-related Internet use by patients. Oncologists were significantly less positive about the consequences of health-related Internet use for the physician-patient relationship and the health-care than rheumatologists. Most of the physicians have never (32%) or only sometimes (42%) referred a patient to a health-related Internet site. Most physicians (53%) found it hard to stay up to date about reliable Internet sites for patients. Conclusion: Physicians are moderately positive about health-related Internet use of their patients, but they only seldom refer their patients to health-related Internet sites. Possibly, offering an up-to-date list with accredited websites for patients would be of help for and stimulate physicians to refer their patients

How age and sex affect the erythrocyte sedimentation rate and C-reactive protein in early rheumatoid arthritis

BACKGROUND: The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are two commonly used measures of inflammation in rheumatoid arthritis (RA). As current RA treatment guidelines strongly emphasize early and aggressive treatment aiming at fast remission, optimal measurement of inflammation becomes increasingly important. Dependencies with age, sex, and body mass index have been shown for both inflammatory markers, yet it remains unclear which inflammatory marker is affected least by these effects in patients with early RA. METHODS: Baseline data from 589 patients from the DREAM registry were used for analyses. Associations between the inflammatory markers and age, sex, and BMI were evaluated first using univariate linear regression analyses. Next, it was tested whether these associations were independent of a patient's current disease activity as well as of each other using multiple linear regression analyses with backward elimination. The strengths of the associations were compared using standardized beta (beta) coefficients. The multivariate analyses were repeated after 1 year. RESULTS: At baseline, both the ESR and CRP were univariately associated with age, sex, and BMI, although the association with BMI disappeared in multivariate analyses. ESR and CRP levels significantly increased with age (beta-ESR = 0.017, p < 0.001 and beta-CRP = 0.009, p = 0.006), independent of the number of tender and swollen joints, general health, and sex. For each decade of aging, ESR and CRP levels became 1.19 and 1.09 times higher, respectively. Furthermore, women demonstrated average ESR levels that were 1.22 times higher than that of men (beta = 0.198, p = 0.007), whereas men had 1.20 times higher CRP levels (beta = -0.182, p = 0.048). Effects were strongest on the ESR. BMI became significantly associated with both inflammatory markers after 1 year, showing higher levels with increasing weight. Age continued to be significantly associated, whereas sex remained only associated with the ESR level. CONCLUSIONS: Age and sex are independently associated with the levels of both acute phase reactants in early RA, emphasizing the need to take these external factors into account when interpreting disease activity measures. BMI appears to become more relevant at later stages of the disease