[Outpatient care and disease burden of rheumatoid arthritis : Results of a linkage of claims data and a survey of insured persons]

[Development of quality standards for patients with rheumatoid arthritis for use in Germany]

Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany.

[Is the prevalence of rheumatoid arthritis truly on the rise?]

A growing number of health insurance data analyses show an increase in the prevalence of rheumatoid arthritis (RA) in Germany. The studies refer to the claims diagnosis of RA, which is more frequent in recent years compared to earlier periods. Depending on the case definition, the numbers vary between 0.6% and 1.4% of the adult population. In this paper, the different studies are reviewed with regard to their data sources, the case definitions of RA and the frequency of the diagnosis. Due to the lack of clinical validation, the prevalence cannot be precisely determined from claims data.

[Prescription frequency of physical therapy for inflammatory rheumatic diseases]

Zielsetzung

Es erfolgte die Untersuchung der Verordnungshäufigkeit von ambulanter physikalischer Therapie (PT) bei Versicherten mit der Diagnose einer rheumatoiden Arthritis (RA), axialen Spondyloarthritis (axSpA), Psoriasisarthritis (PsA) oder eines systemischen Lupus erythematodes (SLE) in den Jahren 2005 bis 2020.

Methodik

Eingeschlossen wurden erwachsene Versicherte der BARMER Krankenversicherung mit Diagnose einer RA (ICD-10: M05, M06), axSpA (M45), PsA (M07.0-3) oder SLE (M32.1,8,9). PT wurden über das bundeseinheitliche Positionsnummernverzeichnis für Heilmittelleistungen identifiziert. Berichtet wird der Anteil an Personen mit mindestens einer Verordnung von PT in den Jahren 2005 bis 2020 nach Alters- und Geschlechtergruppen. Außerdem wurden die Anzahl und die Dauer der Verschreibungen verglichen, und es wurde analysiert, ob Versicherte mit fachärztlichem Kontakt häufiger PT erhalten.

Ergebnisse

Im Jahr 2020 erhielten 43 % (SLE), 46 % (RA, PsA) und 49 % (axSpA) der Versicherten mindestens eine PT-Verordnung. Am häufigsten wurde Krankengymnastik rezeptiert (37 %), gefolgt von manueller Therapie (14 %) und Thermotherapie (10 %). Seit 2005 hat sich der Anteil der Versicherten, die Krankengymnastik erhalten, nicht verändert. Manuelle Therapie wird zunehmend verordnet (+7 %), während Massagen (−10 %), Thermotherapie (−7 %) und Elektrotherapie (3 % in 2005, 2 % in 2020) rückläufig sind (Zahlen zu RA). Auch die Anzahl der Verschreibungen hat sich seit 2010 nicht wesentlich verändert. Versicherte in orthopädischer Betreuung erhalten häufiger PT als Versicherte in hausärztlicher oder internistisch-rheumatologischer Betreuung; 61- bis 80-jährige Patientinnen werden am häufigsten mit PT behandelt.

Schlussfolgerung

Etwas weniger als die Hälfte aller Versicherten mit RA-, axSpA-, PsA- oder SLE-Diagnose erhalten eine ambulante Verordnung von PT. Dieser Anteil hat sich in den letzten 15 Jahren kaum verändert.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00393-022-01180-x) enthält die Tabellen S1–S3 und die Abbildungen S1–S2.

Technische Alltagshilfen in der Rheumatologie – Was ist sinnvoll, was ist bewiesen, welche Perspektiven gibt es?

Einschränkungen der Alltagsaktivität sind ein relevantes gesundheitliches Problem bei Patienten mit entzündlich-rheumatischen Systemerkrankungen. Technische Alltagshilfen nehmen in der Rehabilitation von diesen Teilhabeeinschränkungen einen hohen Stellenwert ein. Wir erläutern Evidenz für den Einsatz von Alltagshilfen und die neuen Entwicklungen auf diesem Gebiet.

[Rehabilitation in Rheumatoid Arthritis]

Die rheumatoide Arthritis stellt unter den Erkrankungen des Bewegungssystems eine besondere Herausforderung für die Rehabilitationsmedizin dar 1. Eine genaue Kenntnis der Erkrankung, inklusive der medikamentösen und der nicht medikamentösen Behandlungsoptionen, ist die wesentliche Voraussetzung für einen nachhaltigen Rehabilitationserfolg und um den berechtigen Anspruch der Erkrankten auf berufliche und soziale Partizipation umzusetzen.

Prescription of analgesics in patients with rheumatic diseases in Germany : A claims data analysis

Objective

To investigate the prescription frequency of analgesics in persons diagnosed with rheumatoid arthritis (RA), axial spondylarthritis (axSpA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE) in 2019 using claims data.

Methods

Persons ≥ 18 years insured in 2019 with a diagnosis of RA (M05, M06), axSpA (M45), PsA (M07.0-3) or SLE (M32.1,8,9) were included. Analgesics were identified by the anatomic therapeutic classification (ATC) system. Reported is the percentage of individuals with ≥ 1 analgesics prescription for the respective rheumatic diagnosis in 2019 and for opioids age-standardized in each of the years 2005–2019. In addition, the proportion of long-term opioid use (prescriptions in ≥ 3 consecutive quarter years) in 2006 and 2019 is compared.

Results

Metamizole (29–33%) was the most commonly prescribed analgesic. Nonsteroidal anti-inflammatory drugs (NSAID)/coxibs were prescribed from 35% (SLE) to 50% (axSpA). Of the patients 11–13% were prescribed weak and 6–8% strong opioids. From 2005 to 2019, the proportion of persons with an opioid prescription remained stable, with similar or slightly decreasing proportions of weak opioids and more frequent prescriptions of strong opioids. The proportion of long-term opioid prescriptions increased from 2006 to 2019 from 8.9% to 11.0% (RA), from 6.9% to 9.1% (axSPA), from 7.8% to 9.5% (PsA), and from 7.5% to 8.8% (SLE), corresponding to a 17–24% increase.

Conclusion

The prescription of opioids for persons with inflammatory rheumatic diagnoses is not as high in Germany as in other countries; however, the proportion of long-term prescriptions has considerably increased. The frequent prescription of metamizole is conspicuous.

[Glucocorticoid-free and low-dose glucocorticoid treatment of rheumatoid arthritis]

Systemic glucocorticoids (GC) are a commonly used component in the treatment of rheumatoid arthritis. The aim of this article is to show the evidence for low-dose GC or GC-free RA treatment regimens. Furthermore, concepts for the de-escalation of GC treatment for RA are presented. There is sufficient evidence in the initial phase that GC treatment in addition to methotrexate (MTX) improves the patient's response to the disease activity as well as the subjective perception of impairments. The dosage of GC, however, needs to be weighed critically and the guideline-based gradual reduction leading eventually to discontinuation must consistently be pursued. In the later phases of the treatment algorithm the risks of GC administration outweigh the benefits and long-term GC treatment should therefore be reserved for exceptional cases. The lowest possible dosage always needs to be determined individually. This can be achieved by using a clinically tested scheme of reducing the prednisolone intake by 1 mg every 4 weeks. The scheme should be considered for patients with a low disease activity or remission due to disease-modifying antirheumatic drug (DMARD) treatment, if they receive 5 mg of prednisolone as long-term treatment. On the whole the positive subjective effects of GC treatment must always be weighed up against the risks of such treatment for RA patients. An ongoing process of readjusting treatment following shared-decision rules must both consistently adapt GC doses and constantly check the indications. Even if a GC-free treatment does not seem realistic, a low-dose GC treatment of RA still is and should be pursued to reduce the risks associated with the treatment.

[Prescription of analgesics in patients with rheumatic diseases in Germany : A claims data analysis. German version]

OBJECTIVE

To investigate the prescription frequency of analgesics in persons diagnosed with rheumatoid arthritis (RA), axial spondylarthritis (axSpA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE) in 2019 using claims data.

METHODS

Persons ≥ 18 years insured in 2019 with a diagnosis of RA (M05, M06), axSpA (M45), PsA (M07.0-3) or SLE (M32.1,8,9) were included. Analgesics were identified by the anatomic therapeutic classification (ATC) system. Reported is the percentage of individuals with ≥ 1 analgesics prescription for the respective rheumatic diagnosis in 2019 and for opioids age-standardized in each of the years 2005-2019. In addition, the proportion of long-term opioid use (prescriptions in ≥ 3 consecutive quarter years) in 2006 and 2019 is compared.

RESULTS

Metamizole (29-33%) was the most commonly prescribed analgesic. Nonsteroidal anti-inflammatory drugs (NSAID)/coxibs were prescribed from 35% (SLE) to 50% (axSpA). Of the patients 11-13% were prescribed weak and 6-8% strong opioids. From 2005 to 2019, the proportion of persons with an opioid prescription remained stable, with similar or slightly decreasing proportions of weak opioids and more frequent prescriptions of strong opioids. The proportion of long-term opioid prescriptions increased from 2006 to 2019 from 8.9% to 11.0% (RA), from 6.9% to 9.1% (axSPA), from 7.8% to 9.5% (PsA), and from 7.5% to 8.8% (SLE), corresponding to a 17-24% increase.

CONCLUSION

The prescription of opioids for persons with inflammatory rheumatic diagnoses is not as high in Germany as in other countries; however, the proportion of long-term prescriptions has considerably increased. The frequent prescription of metamizole is conspicuous.

[Cost of illness in axial spondylarthritis for patients with and without tumor necrosis factor inhibitor treatment: results of a routine data analysis]

BACKGROUND

Tumour necrosis factor-alpha inhibitors (TNFi) are an effective but expensive treatment option in axial spondylarthritis (axSpA) patients who fail to achieve disease control under conventional treatment.

OBJECTIVE

The aim of this study was to assess the cost of illness in axSpA patients treated with and without TNFi.

METHODS

Using German health insurance data, patients with axSpA who newly received TNFi between 2011 and 2015 were identified and matched by age and sex to a reference group of patients with axSpA without TNFi treatment. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy and for productivity loss due to absence from paid work were analyzed over a 2-year period. In patients treated with TNFi , the 2‑year period included 1 year before and 1 year after the initiation of TNFi.

RESULTS

Data from 1455 axSpA patients who received TNFi treatment were included in the analyses. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss significantly decreased after initiation of TNFi. Mean total costs increased from € 6075 in the year prior to TNFi initiation to € 27,871 in the year after TNFi initiation. Excluding costs for TNFi, total costs decreased by 22% to € 4761. Mean total costs among the reference group of 1455 age and sex-matched axSpA patients who did not receive TNFi remained stable over 2 years: € 3939 in the first year vs. € 3832 in the second year.

CONCLUSION

Initiation of TNFi treatment led to a sharp increase in the total costs of axSpA patients. Part of this increase was offset by a decrease of costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss. In patients who did not receive TNFi, the costs remained stable over 2 years.

Long-term trends in rheumatology care : Achievements and deficits in 25 years of the German national rheumatology database

BACKGROUND

Since 1993, data on the care and quality of life of patients with inflammatory rheumatic diseases have been collected in the German National Database (NDB) of the regional collaborative rheumatology centers.

OBJECTIVE

In this review long-term trends on treatment, disease activity and gainful employment of the most common inflammatory rheumatic diseases are presented and the most important analyses from 25 years of the NDB are summarized.

METHODS

Between 15 and 17 rheumatological institutions take part in the NDB and once a year collect data from a total of more than 10,000 patients. The rheumatologists document the disease status and care, the patients report on their state of health and the effects of the disease.

RESULTS

The biologics era at the beginning of the twenty-first century has led to changes in the therapeutic spectrum of most inflammatory rheumatic diseases, especially in rheumatoid arthritis and ankylosing spondylitis. Some basic therapies formerly used are hardly used anymore and glucocorticoids are used less frequently. Methotrexate has remained the standard therapy for rheumatoid arthritis over the years. Nowadays, nearly 30% of patients with rheumatoid arthritis receive treatment with biologics. Disease activity, functional and social restrictions have decreased across all diseases.

CONCLUSION

The improved health status of many patients with rheumatic diseases confirms the high level of care provided by the rheumatism centers involved in the NDB. The increasing specification of measuring instruments and the standardization of documentation systems are major challenges that the NDB will have to face in the coming years if it is to remain in the digital age.

[Health care and disease burden in persons with axial spondyloarthritis in Germany]

BACKGROUND

Only very few data are available on the comprehensive care in patients with axial spondylarthritis (axSpA), one of the most frequent inflammatory rheumatic disease.

OBJECTIVE

Description of the comprehensive care and common prescription patterns of medications and other therapies in patients with axSpA depending on the type of medical care by rheumatologists or nonrheumatologists.

METHODS

A cross-sectional analysis was performed based on claims data of the BARMER health insurance company (in 2015) and a questionnaire, which was sent to a representative sample of patients with axSpA (International Classification of Diseases, 10th revision, German modification, ICD-10-GM, code M45) aged 18-79 years. A stratified sample of 5000 patients was used. The patients received a postal questionnaire including questions regarding the disease, health-related and psychological parameters and socioeconomic factors. Claims data consisted of demographic factors, medicinal and nonmedicinal treatment and the extra-articular manifestations inflammatory bowel disease, psoriasis and uveitis.

RESULTS

A total of 1741 patients (mean age 55.9 years, female 46.4%, 86.2% Human Leucocyte Antigen[HLA]-B27 positive) confirmed the diagnosis and answered the questionnaire. The mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was 4.5 and the mean Bath Ankylosing Spondylitis Functional Index (BASFI) 4.1. Of the patients 46% were treated by rheumatologists. There was a substantial difference between patients in rheumatological care and those who were not in rheumatological care regarding prescriptions for drug treatment of axSpA (91.8% versus 66.4%). This difference was especially prominent for prescriptions of biologic disease-modifying antirheumatic drugs: 34.1% of patients in rheumatological care versus 3.1% of patients treated by nonrheumatologists (p < 0.0001), despite similar disease activity in both groups.

CONCLUSION

The data show that the majority of patients diagnosed with axSpA did not receive regular care from rheumatologists. This seemed to be associated with insufficient medicinal care at least in some of these patients.

[Which patients with rheumatoid arthritis do not receive DMARD treatment? Analysis of data from the German Collaborative Arthritis Centers]

BACKGROUND

The vast majority of patients with rheumatoid arthritis (RA) included in the national database of the German Collaborative Arthritis Centers are treated with disease-modifying antirheumatic drugs (DMARD). The clinical and patient-related characteristics of patients who did not have DMARD treatment in the longer term were investigated.

METHODOLOGY

Between 2012 and 2016 a total of 10,289 patients with RA were documented. Patient characteristics, disease activity and severity, comorbidities and concomitant treatment were descriptively evaluated. Patients who were without DMARDs for more than 1 year and not in remission (disease activity score 28, simple disease activity index or Boolean remission) were analyzed separately. Logistic regression was used to investigate which variables were associated with DMARD treatment.

RESULTS

A total of 426 patients were ≤1 year without DMARDs, 1090 > 1 year without DMARDs and 8773 (85%) currently had DMARD treatment. Of the patients who were without DMARDs for more than 1 year, 51% were in remission. Even if no remission criteria were met, the rheumatologists nevertheless found the strived for RA situation in the majority of patients. Of the patients who were without DMARDs for more than 1 year, 13% received glucocorticoid treatment >5 mg/day. In patients with a high degree of severity (odds ratio, OR severe vs. asymptomatic/mild 2.33, 95% confidence interval, CI 1.80;3.02) or positive rheumatoid factor (OR 2.24, CI 1.96;2.56) the chance of receiving DMARD treatment was twice as high. Existing comorbidities did not reduce the chance of receiving DMARD treatment.

CONCLUSION

The RA patients in the national database who had no DMARDs for more than 1 year were mostly in remission or with low disease activity. Signs of inadequate disease control were found in only 11% of all patients without DMARD treatment.

[Reality of care for musculoskeletal diseases at the population level : Results of the PROCLAIR collaborative project. German version]

BACKGROUND

The objective of the research consortium PROCLAIR was to gain population level knowledge on the treatment of patients with rheumatoid arthritis (RA), axial spondylarthritis (axSpA) and osteoarthritis (OA) in Germany.

AIMS

A main question of the consortium was whether it is possible to identify groups of people who were exposed to a particular risk of undersupply or oversupply of treatment. In addition, the study investigated the validity of claims data for these diseases as a basis for further studies.

PATIENTS AND METHODS

Cross-sectional surveys were carried out among insurees of the BARMER statutory health insurance fund whose claims data included RA, axSpA and OA diagnoses. The questionnaire data were linked with the claims data of the insured persons if they agreed.

RESULTS

In all three diseases risk groups for care deficits could be identified. Persons with RA who are not treated by a specialist have less access to drug treatment. Physical therapy is prescribed for all three diagnoses at a low level, even for people undergoing joint replacement surgery. A connection between depressive symptoms and disease activity or function in axSpA was shown. In addition to the results relevant to care, the PROCLAIR network has also made contributions to critically assess the quality of health insurance data.

DISCUSSION

The combination of billing data with survey data enables a comprehensive description of the treatment of musculoskeletal diseases. Particularly relevant factors are the specialization of the physician, sociodemographic parameters of the patients and the region of residence. In particular, access to treatment cannot be investigated in randomized clinical trials.

[Non-drug treatment of rheumatoid arthritis : An analysis of claims data and a survey of insured persons (Project PROCLAIR)]

BACKGROUND

Only small amounts of data are available on the prescription frequency of physical therapies (PT) for patients with rheumatoid arthritis (RA).

OBJECTIVE

The aim of the study was to evaluate prescription frequencies of PT considering functional status and sociodemographic factors.

MATERIAL AND METHODS

A total of 98,963 adults diagnosed with RA in 2013 were identified in claims data from the BARMER health insurance. A questionnaire was sent to a representative sample of 6193 people requesting information on the disease status. Of these 2535 persons were included who agreed to the linking of the questionnaire and claims data and who confirmed a diagnosis of RA. From the routine claims data the prescription of PT and occupational therapy as well as the medical discipline of the prescribing physician were analyzed. Multivariable logistic regression was conducted to determine which variables (age, sex, M05/M06 diagnosis, residential area, income, functional status and rheumatological care) were associated with the use of PT.

RESULTS

In 2015 a total of 47% of the study population received PT (35% physiotherapy, 15% thermotherapy, 15% manual therapy, 2% electrotherapy and 6% massage) and 3% occupational therapy. Of the PT prescriptions 37% were issued by general practitioners, 27% by orthopedists and 18% by rheumatologists. Women and persons living in the eastern states of Germany and patients with high functional impairment were prescribed PT more often. Income, educational status, seropositivity and rheumatological care did not have any influence on the frequency of prescription of PT.

CONCLUSION

There are deficits in the outpatient prescription of PT but without indications of an undersupply of population groups due to low socioeconomic status. In contrast to the prescription of disease-modifying antirheumatic drug (DMARD) treatment, PT is predominantly prescribed by general practitioners.

Patterns of the initiation of disease-modifying antirheumatic drugs in incident rheumatoid arthritis: a German perspective based on nationwide ambulatory drug prescription data

This study aimed at providing a current and nearly complete picture of the patterns of the initiation of disease-modifying antirheumatic drugs (DMARDs) in patients with newly diagnosed RA. Based on ambulatory drug prescription data and physician billing claims data covering 87% of the German population, we assembled a cohort of incident RA patients aged 15-79 years (n = 54,896) and assessed the prescription frequency of total DMARDs, conventional synthetic (csDMARDs) and biologic DMARDs (bDMARDs) within the first year of disease. Using multiple logistic regression, we estimated the chance of early DMARD receipt based on age, sex, serotype and specialty of prescribing physician while controlling for region of residence. In total, 44% of incident RA patients received a DMARD prescription within the first year of disease. In multiple regression, younger patients (< 35 years) had 1.7-fold higher chances of receiving a csDMARD than patients aged ≥ 65 years [odds ratio (OR): 1.65 with 95% confidence interval (CI) 1.51-1.80] and almost tenfold higher chances to receive a bDMARD [OR (95% CI) 9.5 (8.0-11.3)]. Seropositivity and a visit to a rheumatologist were positively associated with DMARD initiation [OR (95% CI) 2.8 (2.6-2.9) and 5.9 (5.6-6.2) for csDMARDs, respectively]. Based on data covering 87% of the German population, the present study revealed that less than half of incident RA patients receive DMARDs within the first year of disease and that marked differences exist according to age. The study highlights the importance of involving a rheumatologist early in the management of RA.

FACTORS INFLUENCING THE EFFICIENCY OF THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS: THE ROLE OF COMORBID MENTAL AND SOMATIC DISEASES

The response rate to therapy for rheumatoid arthritis (RA) rarely exceeds 60%. Mental disorders (MDs) of the anxiety-depressive spectrum (ADS) and cognitive impairment (CI) substantially affect the evaluation of the efficiency of RA therapy. Adequate psychopharmacotherapy is one of the possible approaches to optimizing the treatment of RA. The factors influencing the efficiency of RA therapy with standard disease-modifying antirheumatic drugs (DMARDs) and biological agents (BAs) in combination with adequate psychopharmacotherapy have not been previously identified. Objective: to determine the predictors of response to therapy in patients with RA receiving DMARDs and BAs with or without adequate psychopharmacotherapy for ADS disorders. Subjects and methods. The investigation included 128 patients (13% men and 87% women) with a reliable diagnosis of RA. At baseline, 75.1% of patients received DMARDs; 7.8% – BAs. ADS disorders were detected in 123 (96.1%) patients. Psychopharmacotherapy was offered to all the patients with MDs; 52 patients agreed to treatment and 71 refused. The following therapeutic groups were identified according to the performed therapy: 1) DMARDs (n = 39); 2) DMARDs + psychopharmacotherapy (n = 43); 3) DMARDs + BAs (n = 32); 4) DMARDs + BAs + psychopharmacotherapy (n = 9). The changes of MDs symptoms and the outcomes of RA were assessed in 83 (67.5%) patients at five-year follow-up. The efficiency of RA therapy was evaluated with DAS28 (EULAR criteria). Predictors of response to therapy were determined using linear regression modeling. Results and discussion. At 5 years, 22 (26.5%) and 37 (44.6%) patients were recorded to show good and moderate responses to therapy, respectively; 24 (28.9%) patients were non-respondents. The linear regression model included 14 factors (p<0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p<0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response.

[Prevalence, comorbidity and interdisciplinary treatment of rheumatoid arthritis - Insurance data on outpatient and inpatient care in Baden-Württemberg]

BACKGROUND

Rheumatoid arthritis (RA) has an increased number of comorbidities compared with the general population.

OBJECTIVE

Study aim was to collect epidemiological data on prevalence, incidence and comorbidities of RA as well as utilization of outpatient and inpatient care services.

MATERIAL AND METHODS

In an age and gender-adjusted case control study, a total of 3.4 million patients insured by the AOK Baden-Württemberg were analysed with respect to visits to physicians, prevalence, incidence and comorbidities of RA. The study was based on out- and inpatient diagnoses from 2013.

RESULTS

The RA prevalence was 0.64% (n = 26,919), the incidence was 0.04%. Patients with RA have significant more comorbidities in almost all diagnosis groups, especially in musculoskeletal and cardiovascular diseases, compared to a control group (n = 181,209). 22.8% of RA patients had not contacted an internist rheumatologist, orthopedist or orthopedic surgeon. Biological disease-modifying anti-rheumatic drugs (DMARDs) were almost exclusively prescribed by internist rheumatologists, while conventional DMARDs were equally prescribed by general practitioners and rheumatologists. Of the RA patients 32.6% were hospitalized at least once a year and were nearly twice as frequently inpatient as the control group.

CONCLUSION

RA patients need more in- and outpatient healthcare services and suffer significantly more often from comorbidities. The general practitioner is the most frequently visited physician. Other consulted physicians are rheumatologists, ophthalmologists, orthopedists/orthopedic surgeons and internists not specialized in rheumatology. The study highlights the need to create consensus treatment algorithms and maintain a close interdisciplinary and intersectoral cooperation and communication.

Rheumatologic care of nursing home residents with rheumatoid arthritis: a comparison of the year before and after nursing home admission

The purpose of this study was to investigate health care for patients with rheumatoid arthritis (RA) before and after admission to nursing homes. Data of a German health insurance fund from persons with diagnostic codes of RA, aged ≥65 years, admitted to a nursing home between 2010 and 2014 and continuously insured 1 year before and after admission were used. The proportion of patients with ≥1 rheumatologist visit and ≥1 prescription of biologic or conventional synthetic disease-modifying antirheumatic drugs (bDMARDs or csDMARDs), glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) in the year before and after admission were calculated. Predictors of rheumatologic care after admission were analyzed by multivariable logistic regression. Of 75,697 nursing home residents, 2485 (3.3%) had RA (90.5% female, mean age 83.8). Treatment by rheumatologists and prescription of antirheumatic drugs decreased significantly in the year after admission (rheumatologic visits: 17.6 to 9.1%, bDMARDs: 2.1 to 1.5%, csDMARDs: 22.5 to 16.5%, glucocorticoids: 46.5 to 43.1%, NSAIDs: 47.4 to 38.5%). 60.2% of patients in rheumatologic care received csDMARDs compared with 14.5% without rheumatologic care. Rheumatologic care before admission to a nursing home strongly predicted rheumatologic care thereafter (OR 33.8, 95%-CI 23.2-49.2). Younger age and lower care level (reflecting need of help) were also associated with a higher chance of rheumatologic care. Rheumatologic care is already infrequent in old patients with RA and further decreases after admission to a nursing home. Patients without rheumatologic care are at high risk of insufficient treatment for their RA. Admission to a nursing home further increases this risk.