Funded by an Arthritis Research Campaign (ARC) PhD Studentship
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RHEUMATOID ARTHRITIS:THE COSTS OF CARE
Dr Nicola J CooperDepartment of Epidemiology & Public Health, University of LeicesterFunded by an Arthritis Research Campaign (ARC) PhD Studentship
Professor Miranda MugfordSchool of Medicine, Health Policy and Practice, University of East AngliaProfessor Deborah Symmons, Dr Nicola WilesARC Epidemiology Unit, University of ManchesterBett Barrett, NOAR Metrologists Norfolk Arthritis Register, St Michaels Hospital, AylshamProfessor David GI Scott, Rheumatology staffNorfolk and Norwich HospitalsGPsNorwich Area Health AuthorityAll individuals with RA who participated in the research
OUTLINECost of illness (COI) studies;
State of knowledge of economic impact of RA; and
Study One: Retrospective study of the secondary health care and second line drug costs of early RA. Study Two: Prospective study of costs of early RA to patient, health service and other agents
COST OF ILLNESS STUDIESDefinition:
Descriptive studies which provide informative data to emphasise the scale and nature of a disease as a health problem and raise the profile of people with that disease as a patient group.
VALUE OF COI STUDIESProvides policy-makers with information on total costs of a disease;
Identifies where major burden of cost might lie in treatment and care of these people;
Helps to prioritise research agendas; &
Provides an indication of potential gains from preventing the condition.
TYPES OF COSTSDirect costs: Borne by the health care system, community & family in directly addressing the problem.
Indirect costs: Mainly productivity losses caused by illness, borne by the individual, family, society or employer.
Psycho-social costs: Usually costs of pain, grief, suffering & loss of leisure time.
PERCENT DISTRIBUTION OF ECONOMIC COSTS OF ILLNESS, BY DIAGNOSIS & TYPE OF COST: 1980 (Adapted from Rice et al,1985)
COHORT CHARACTERISTICS BY STUDY
MEAN DURATION OF DISEASE (YRS)
MEAN HAQ SCORE
Meenan et al 1978
Liang et al 1984
Lubeck et al 1986
Wolfe et al 1986
Jacobs et al 1988
Lanes et al 1997
Clarke et al 1997
van Jaarsveld et al 1998
Jonsson et al 1992
Gabriel et al 1997b
Gabriel et al 1997a
KEY FINDINGSMean costs per person per annumDirect = UK3,575 (US$5,720 )[Range: UK1,189 to UK7,189]
Indirect = UK3,060 (US$4,900 )[Range: UK 676 to UK11,514]
Ratio Direct : IndirectRanged from 0.40 to 3.00
KEY FINDINGS (cont.)
Annual direct costsRA = UK4,546 (US$7,274) non-RA= UK1,198 (US$1,917)
Annual indirect costsRA = UK1,171 (US$1,874)non-RA= UK 531 (US$ 849)
CONCLUSIONFew previous studies of the cost of RA in the UK
Previous studies took a top down rather than a bottom up approach
Few previous studies considered the cost to the individual patient and their family
RECOMMENDATIONS FOR FUTURE COI STUDIES1.Report direct & indirect costs separately as well as in aggregate;
2.Identify different components of costs to identify budgets on which major economic burden falls;
3.State data sources & unit costs to allow estimates to be reworked for different locations;
4.Test sensitivity of results by varying assumptions underlying key parameters.
Objective:A retrospective study to estimate the secondary health service care & 2nd line drug costs over first 5 years of inflammatory polyarthritisSTUDY ONE
STUDY POPULATION433 people with inflammatory polyarthritis (IP), who registered with the Norfolk Arthritis Register (NOAR) project in 1990/91.
Selection criteria:1) Aged over 16 years;
2) Swelling of two or more joints;
3) Disease duration 4 weeks; &
4) Disease onset after January 1989.
Of which, 208 people (48%) diagnosed as RA (defined by the ACR 1987 revised criteria).
NORFOLK ARTHRITIS REGISTER (NOAR)Primary care based inception cohort of patients with inflammatory polyarthritis (IP)
NOAR MethdologyPatients seen by a metrologist within 2 weeks of notificationFollowed annually for at least five yearsAnnual assessment includes Health Assessment Questionnaire (HAQ)
DATA SOURCESRESOURCE USE DATA:NOAR Database (e.g. No. of outpatient visits & inpatient stays, medications, patient characteristics)Hospital Medical Records & H.I.S. (e.g. Length of hospital stay & department - Rheumatology or Orthopaedic)GP Guidance Notes (e.g. Typical treatment regimes and routine laboratory tests)
DATA SOURCES (cont.)UNIT COSTS:British National Formulary (e.g. Medication)Hospital Laboratories (e.g. Laboratory tests)Hospital Finance Department (e.g. Inpatient day & outpatient visit)COSTING EQUATION n m TOTAL COST = (frequency)ij* (unit cost)i i=1 j=1
wherei = ith individual (i = 1,......n)j = jth service received (j = 1,......m)
N = 225
N = 208
Mean: 52 (se 1.19)
Mean: 56 (se 1.08)
% smoking now
% smoked past
113.6% missing data; 214.6% missing data.
MEAN OUTPATIENT, INPATIENT & 2ND LINE DRUG COSTS PER PERSON PER YEAR (RA)Cost
KEY RESULTS[Cost estimates expressed in 1997/8 UKs]Total 5-year cost:RA = 487,230Other IP = 193,590Mean annual cost per person RA = 410 (CI 315 to 505)Other IP= 150 (CI 111 to 189Cost breakdown (RA-cohort): 55% Inpatient stays; 9% Outpatient visits & 36% 2nd line drugs
KEY RESULTS (cont.)RA-Cohort11% incurred no costs.23% (who all incurred inpatient costs) responsible for approx. 75% of total 5-yr costs.High costs over first 5yrs related to: - HAQ score 1.0; - Presence of Rheumatoid factor.
COSTS OF EARLY RA IN THE UKBased on 15,000 new cases of RA per year (Symmons et al 1994):
Total 5-year secondary care and 2nd line drug costs (including monitoring) for new cases approx. 30.9 million [1997/8].- 17.0m = Inpatient care;- 2.8m = Outpatient care; &- 11.1m = 2nd line drugs.
Objective:A prospective longitudinal study to estimate the costs to the patient, their families and the health service, over first 5 years of inflammatory polyarthritisSTUDY TWO
OBJECTIVESPART A: To develop a resource-use and expenditure questionnaire for self-completion by early IP individuals over a 6-month periodPART B: To estimate the costs associated with early IP (Health service (e.g. health professionals time, hospital costs, prescribed medication) and Non-health service (e.g. travel time, informal care, lost time from work, aids & modifications, over-the-counter medication, alternative therapies)
PART A: METHODSStudy methods:2 Focus Groups3-Month Data Collection (Pilot & validation)Study population:Focus groups: RASCAL & NOAR patientsPilot & validation study: 12 NOAR & 12 Cheshire patients with early IP
OPENING QUESTIONS:1. How would you spend your time differently if you did not have arthritis?2. What would you say was the most significant consequence of your arthritis?3. How has your lifestyle changed to accommodate your arthritis?MORE SPECIFIC QUESTIONS:4. Tell me about the aids you have and modifications you have had done to help you around the home...What about outside the home?5. Have you become more reliant on other people (e.g. friends, neighbours, relatives, social services) since the onset of your arthritis?.If so, who?.How do they help i) you, ii) your children, iii) other dependants?FOCUS GROUPS QUESTIONS ROUTE
6. How do you cope with everyday chores such as shopping and housework?7. Has your arthritis had an impact (both positive and negative) on important events in your life?.Changing pattern of work / job?.Family relationships?.Accommodation?8. Can you describe how your arthritis has affected you emotionally?9. Have your family, relatives and/or friends incurred any additional costs as a results of your arthritis?CLOSING QUESTION:Following a summary of the issues and topics discussed..10. In keeping with the discussion that has just occurred, are there any other forms of costs that you think should be considered?FOCUS GROUPS QUESTIONS ROUTE (cont.)
RESULTSForgone leisure time / activities..planning in advance is a mustnot actually just go and do it - wed have to plan is it feasible? My husband did